Get Non-covered Services: Financial Disclosure Form

This guide provides a comprehensive walkthrough for filling out the Non-Covered Services: Financial Disclosure Form online. By following these steps, you can ensure that all required information is accurately provided, facilitating a smooth experience in managing your healthcare finances.

Follow the steps to complete your form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the provider name at the top of the form. Ensure that you enter the full name of the chiropractic provider offering the services.
3. Next, input the address details including street address, city, state, and zip code of the provider's location to maintain accurate records.
4. Enter the phone number of the provider to facilitate direct contact if necessary.
5. Read the introductory paragraph carefully. This section outlines the purpose of the form and highlights your agreement to be financially responsible for non-covered services.
6. In the treatment plan section, provide the start and end dates of your treatment plan. Remember, the duration cannot exceed 12 weeks.
7. In the non-covered services section, fill in the details of each service provided. Enter the expected cost per visit for each service and initial next to each to acknowledge the charges.
8. Indicate your understanding of the services' reimbursement status by checking the appropriate box that best describes your situation.
9. Ensure you sign and date the form, as well as have your provider or authorized health care representative also provide their signature for validation.
10. Finally, save the changes you made to the form, and download, print, or share it as required.

Complete your forms online with confidence and ensure you have all necessary documentation ready.