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Online Forms

Coastline Chiropractic and Rehabilitation Center offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

Please use the following links to download our patient paperwork. Print them and bring them with you to your appointment!

For New Patients:

New Patient Health History Form

Información para el paciente y la salud historia – Español

For Returning Patients:

Patient Update Form

HIPAA Privacy Policy:

HIPAA Notice

Medical Records Release:

CCRC Medical Records Release

Our Insurance Policies

GROUP OR INDIVIDUAL INSURANCE
We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding your financial responsibilities at our office, please do not hesitate to ask.

PATIENTS WITHOUT INSURANCE
An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard, Visa, American Express or Discover cards.

“ON THE JOB” INJURY (Worker’s Compensation)
If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.

MEDICARE
We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover, which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20% as well as any non-covered services. Our office completes and files the forms for Medicare at no charge.

SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.

CONTACT US TODAY

We look forward to hearing from you

Location

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Office Hours

Our Regular Schedule

Coastline Chiropractic and Rehabilitation Center

Monday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Tuesday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Wednesday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Thursday:

10:00 am-1:00 pm

2:00 pm-7:00 pm

Friday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Saturday:

Closed

Sunday:

Closed