Please use the following links to print and fill out our insurance coverage and patient health history forms. The forms are formatted in Adobe Acrobat. In order to view them you will need Adobe Acrobat Reader installed on your computer. If you do not have Adobe Acrobat Reader, you can click here to download it FREE.
Patient Intake Forms
(Insurance and Private Pay)
Personal Injury Intake Form
(Auto Accidents and Slip and Falls)
GROUP OR INDIVIDUAL INSURANCE
We will verify your insurance coverage for you. The benefits that are quoted by the insurance are not a guarantee of payment. As a courtesy, we will file a claim for you and wait for payment for 60 days. Per your explanation of benefits, you will be billed for any deductibles, co-pays, co-insurance amounts and non-covered services. It is ultimately the patients’ responsibility to make sure the services are paid for. We are happy to answer any questions you may have regarding the billing process.
PATIENTS WITHOUT INSURANCE
Due to the limited coverage and sometimes no insurance coverage at all, we do offer at time of service discounts for our patients. We do not want a patient’s health to become a burden to him or her financially. We accept cash, personal checks, Visa and MasterCard (with a nominal fee)
"ON THE JOB" INJURY (Worker’s Compensation)
Worker’s Compensation Insurance is applicable when you are hurt on the job. After informing your employer of your injuries, you will be given the Workers Compensation Carrier name and information. We will be happy to verify your claim and obtain authorization for treatment. Dr. Lechner is on most work compensation insurance network panels.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
If you are injured in an automobile accident, you may be covered under the automobile insurance policy. We will verify your coverage for you. If an attorney represents you please inform us, as we will work under a lien. We will bill your insurance company as a courtesy after completion of treatment and will wait for settlement from the insurance company. Ultimately, all fees for services are the responsibility of the patient.
Our office accepts Medicare. Medicare only covers spinal manipulation. They pay 80% of the allowable fee after the deductible has been satisfied. The patient is responsible for deductibles and the co-insurance amount (20% of allowable). We will bill your insurance as a courtesy.
Please inform us of any secondary insurance you may have. Some secondary insurance may cover your co-insurance amount.