INTAKE 1 – Good Faith Estimate

INTAKE 2 – Notice of Privacy Practices

INTAKE 3 – Chiropractic Consent Form

INTAKE 4 – HIPAA Verbal Release

MVA & PI DISCLOSURE

MVA INITIAL VISIT

INSURANCE PLAN
ABN

MEDICARE
ABN

Messa ABN

DIAGNOSIS CODE CHECK-OFF

SPIRAL DESKTOP REFERENCE

Corrective/symtomatic
plan

Corrective/symtomatic
plan (payment)

Decompression
add on

CARE PLAN
INSTRUCTIONS

Report of
Findings

Report of Findings
Presentation

SUPPORT
RECOMMENDATIONS

CONTINUED CARE

ACUTE BRIDGE CARE

PLANS
FREQUENCY CHART

VISIT FREQUENCY
CHART

MRI
SUMMARY

RECORD RELEASE
INCOMING

RECORD RELEASE
OUTGOING VETERANS

RECORD
RELEASE OUTGOING

RMI
PREAUTHORIZATION

WORK OR
SCHOOL EXCUSE

WORK OR SCHOOL
RESTRICTIONS

CONTINUED CARE
CANCELLATION

CVP/SVP
CANCELLATION

EXTENSION OF
VISIT PLAN

GENERAL
REQUEST

EXERCISE & SUPPORT
CARD

Refusal of Re-Evaluation
with X-Rays

REFUSAL OF RE-EVAL
WITHOUT X-RAYS

Continued Care
Cash

Continued Care Cash Decomp. Add On

Continued Care
Insurance

Continued Care
Notice

RE-EVALUATION

Case
Summary

MVA
Re-Eval

MVA
Treatment Justification