New Patient Forms

New Patient Information & Forms

Dr. Moore is currently a participating provider with Blue Cross Blue Shield, United Healthcare, and Medicare.

INSURANCE PROCEDURE:

Please call the information phone number located on your insurance card for insurance benefits for chiropractic benefits.

ATTENTION: Please contact the office before filling out these forms.

The 4 forms below can be completed at any time BEFORE your scheduled visit:

The forms below (that you were instructed to fill out) should be completed ON THE DAY of your scheduled visit, so that they will be current.

REMINDER: Bring Insurance Card the Day of your Initial Visit.

The following Information should be brought if your case is related to an Auto Accident:

Insurance Information (Both Party at Fault and Personal)

Claim Number

Police/Accident Report

Any Emergency Room documents pertaining to incident (If Applicable)

Any X-rays, MRI, Radiology, etc. Reports (If Applicable)

The following Information should be brought if your case is related to a Personal Injury:

Insurance Information (Both Party at Fault and Personal)

Claim Number

Accident Report (if any)

Any Emergency Room documents pertaining to incident (If Applicable)

Any X-rays, MRI, Radiology, etc. Reports (If Applicable)

The following Information should be brought if your case is related to a Workers Compensation:

Employer Information (Supervisor Contact info)

Claim Number & Date of Incident

Any Emergency Room documents pertaining to incident (If Applicable)

Any X-rays, MRI, Radiology, etc. Reports (If Applicable)