*there is a printable word document of this page within the intake paperwork*

Will my insurance cover a visit with Dr. Jess?

Here’s how to find out…

• Please call your insurance company to obtain the following information
  

1.  Beginning date of coverage:Ending date of coverage:

2.  Does your plan have Chiropractic benefits?   ☐ Yes   ☐ No  **

3.  If yes:

In- Network BenefitsOut-of Network Benefits

• Deductible:
  

• Amount met so far
  

• Co-pay/ Co-insurance amount:
  

• % Covered:
  

• Maximum coverage $ amount:
  

• $ met so far
  

• Maximum # visits per year:
  

• # met so far
  

4. Is there any coverage for ☐ Massage Therapy  ☐  Acupuncture  ☐ Naturopathy  ☐ Physical Therapy

Notes:

5. Annual date of renewal:

6. Name of representative spoken with: Date:

** If your plan is with Blue Cross Blue Shield or Lifewise, I am considered an in-network provider.

If it is with anyone else, I would be an out-of-network provider.

4160 SE Division Street    Portland, OR    97202    contact: growingcarepdx@gmail.com    fax: 888-869-9521

4160 SE Division Street    Portland, OR    97202    contact: growingcarepdx@gmail.com    fax: 888-869-9521