Forms

PATIENT INFORMATION:
If this is your first visit, and you are NOT filing a worker’s compensation or personal injury claim, please use the New Patient Intake Form.

If you were involved in a motor vehicle accident or work injury, use the Personal Injury Form. If you have retained an attorney in order to pursue an MVA or Worker’s Comp case, please sign the Doctor-Attorney Lien.

If you are scheduled to only receive physical therapy (massage), please use the Massage Intake Form.

If you haven’t been to our clinic in more than 5 months, please fill out the Patient History Update.

Consent to Treatment forms:
Clinic Policy Assignment and Release
Oregon HIPPA Form
Consent to Treatment of a Minor
Graston Technique Agreement – Insurance may not cover the Graston modality, because it is a relatively new advance in health care. This form acknowledges that the patient may be responsible for that portion of their treatment.

INSURANCE:
If you will be using insurance, please call them to verify your chiropractic and massage coverage. The Insurance Questions Form will assist you in obtaining this information.

If you are covered by American Specialty Health/HealthNet, you may use these forms to continue authorizations for your treatments:
Patient Progress- Massage
Patient Progress- Chiropractic
Initial Health Status

If you have Optum Health (UHC, GreatWest), you can use this form for authorization to continue treatment: Optum Patient Summary Form

If your insurance does not have sufficient Alternative Care (Chiropractic and Massage) coverage, or if you have a high deductible, you may choose to opt out of using your insurance for treatments here. If so, please sign the Change to Cash Day of Service Payment Form.

RECORDS:
To transfer your medical records to or from another institution, or to receive them yourself, you can use our Request for Records Form.