Document Library

1500 Claim form

      • 1500 02-12 With Calculations(Sign up to download.)
      • 1500 Claim Form Instruction Manual 2019 07-v7(Sign up to download.)

      COVID Forms

          • COVID-19 - CDC Health Professionals Guidelines(Sign up to download.)
          • COVID-19 - CDC Stop The Spread Flyer(Sign up to download.)
          • COVID-19 Informed Consent Form(Sign up to download.)
          • COVID-19 Office Safety Protocols(Sign up to download.)

          CPT

              • CPT Modifiers(Sign up to download.)
              • Preventative Medicine & Obesity Screening And Counseling - Coding And Reimbursement(Sign up to download.)
              • Prolonged Services 99354-99355(Sign up to download.)
              • Relative Value Units CPT (Sign up to download.)
              • Review Of Records 99358-99359(Sign up to download.)
              • Taping And Strapping(Sign up to download.)

              Correpondance Letters

                  Denial of E&M with CMT

                • Denial Of E&M Code(Sign up to download.)
                • Denial Of E&M Code(Sign up to download.)

                  • Denials per CCI Edits

                • 97110-97124 Denial When Billed With CMT(Sign up to download.)
                • 97110-97124 Denial When Billed With CMT(Sign up to download.)
                • 97140 Denial With CMT Aetna Et Al(Sign up to download.)
                • 97140 Denial With CMT Aetna Et Al(Sign up to download.)

                  • Insurance Disputing Fees

                • Usual Customary And Reasonable Fee Reduction(Sign up to download.)
                • Usual Customary And Reasonable Fee Reduction(Sign up to download.)

                  • Insurance requesting a refund

                • Insurance Requesting A Refund, Extended Response(Sign up to download.)
                • Insurance Requesting A Refund, Extended Response(Sign up to download.)
                • Insurance Requesting A Refund(Sign up to download.)
                • Insurance Requesting A Refund(Sign up to download.)

                  • Maintenance and Medical Necessity Denials

                • Denial Of 97014 As Experimental(Sign up to download.)
                • Denial Of 97014 As Experimental(Sign up to download.)
                • Maintenance Care Denial(Sign up to download.)
                • Maintenance Care Denial(Sign up to download.)

                  • Patient Collection

                • Patient Late Pay When They Receive The Check(Sign up to download.)
                • Patient Late Pay When They Receive The Check(Sign up to download.)
                • Patient Late Pay When They Receive The Check And Do Not Want To Pay In Full(Sign up to download.)
                • Patient Late Pay When They Receive The Check And Do Not Want To Pay In Full(Sign up to download.)
                • Patient Late Pay(Sign up to download.)
                • Patient Late Pay(Sign up to download.)

                  • Personal Injury

                • Attorney Holding Med Pay(Sign up to download.)
                • Attorney Holding Med Pay(Sign up to download.)
                • Attorney Late Payment With Signed Lien(Sign up to download.)
                • Attorney Late Payment With Signed Lien(Sign up to download.)
                • Attorney Status Of Claim(Sign up to download.)
                • Attorney Status Of Claim(Sign up to download.)
                • Attorney Cover Letter With Lien(Sign up to download.)
                • Attorney Cover Letter With Lien(Sign up to download.)
                • Attorney Negotation To Reduce Settlement Rejection(Sign up to download.)
                • Attorney Negotation To Reduce Settlement Rejection(Sign up to download.)
                • Attorney Not Paying Settled Claim(Sign up to download.)
                • Attorney Not Paying Settled Claim(Sign up to download.)
                • Attorney Paying Reduced Amount Rejection(Sign up to download.)
                • Attorney Paying Reduced Amount Rejection(Sign up to download.)
                • Deposition Expert Witness Fees(Sign up to download.)
                • Deposition Expert Witness Fees(Sign up to download.)
                • Excess Med Pay HMO Primary(Sign up to download.)
                • Excess Med Pay HMO Primary(Sign up to download.)
                • Excess Med Pay No Primary Health Insurance(Sign up to download.)
                • Excess Med Pay No Primary Health Insurance(Sign up to download.)
                • Low Property Damage Explanation(Sign up to download.)
                • Low Property Damage Explanation(Sign up to download.)
                • Patient Late Payment Of Settled Claim 2(Sign up to download.)
                • Patient Late Payment Of Settled Claim 2(Sign up to download.)
                • Patient Late Payment Of Settled Claim(Sign up to download.)
                • Patient Late Payment Of Settled Claim(Sign up to download.)

                  • Termination of PPO Contract

                • Termination Of PPO Contract(Sign up to download.)
                • Termination Of PPO Contract(Sign up to download.)

                  • Timely Filing Dispute

                • Timely Filing Dispute(Sign up to download.)
                • Timely Filing Dispute(Sign up to download.)

                  • Withdrawal from care

                • Withdrawal From Care(Sign up to download.)
                • Withdrawal From Care(Sign up to download.)

                  • Documentation

                      • Basic Chiropractic Documentation(Sign up to download.)
                      • Documentation Of Timed Therapeutic Services(Sign up to download.)
                      • Medicare Chiropractic Documentation(Sign up to download.)

                      External Causes of Injury ICD9 & ICD10 Codes

                          • E Codes ICD9 External Causes Of Injury(Sign up to download.)
                          • V Codes ICD10 Auto Accidents(Sign up to download.)
                          • V, W, X, Y, & Z Codes ICD 10 Morbidity & Health Status Codes(Sign up to download.)

                          Financial Agreements

                              Credit Card Authorization

                            • Credit Card Authorization For Past Due Payments(Sign up to download.)

                              • General

                            • Financial Policy & Agreement (PDF)(Sign up to download.)
                            • Financial Policy & Agreement (editable)(Sign up to download.)
                            • Health Insurance Chiropractic (PDF)(Sign up to download.)
                            • Health Insurance Chiropractic (editable)(Sign up to download.)

                              • Hardship

                            • Financial Hardship Agreement (PDF)(Sign up to download.)
                            • Financial Hardship Agreement (editable)(Sign up to download.)

                              • Medicare

                            • Medicare Explanation Of Benefits, Chiropractic 2022(Sign up to download.)

                              • Personal Injury

                            • Personal Injury Financial Agreement (PDF)(Sign up to download.)
                            • Personal Injury Financial Agreement (editable)(Sign up to download.)

                              • Surprise Billing

                            • Financial And Good Faith Chiropractic IN NETWORK(Sign up to download.)
                            • Financial And Good Faith Chiropractic OUT OF NETWORK(Sign up to download.)

                              • Forms

                                  Assignment of Benefits

                                • Assignment Of Benefits(Sign up to download.)

                                  • Examination

                                • Examination Report (single Page)(Sign up to download.)
                                • Orthopedic And Neurological Examination (2 Pages)(Sign up to download.)
                                • Review Of Systems(Sign up to download.)

                                  • History, Consultation & Examination

                                • Case History 7.13.21(Sign up to download.)
                                • Personal Injury Intake 7.13.21(Sign up to download.)
                                • Review Of Systems(Sign up to download.)

                                  • Personal Injury Lien

                                • Notice Of Doctors Lien(Sign up to download.)

                                  • HCPCS Orthotics and DME Common Codes

                                      • HCPCS Common Codes(Sign up to download.)

                                      HIPAA

                                          • Business Associate Agreement Editable(Sign up to download.)
                                          • Business Associate Agreement PDF(Sign up to download.)
                                          • HIPAA Privacy Notice Editable(Sign up to download.)
                                          • HIPAA Privacy Notice PDF(Sign up to download.)
                                          • Request For Records(Sign up to download.)

                                          Informed Consent

                                              • Informed Consent Presentation Packet- NCC(Sign up to download.)
                                              • Informed Consent To Care Chiropractic(Sign up to download.)

                                              Insurance Chiropractic Coverage Policies

                                                  ASHN

                                                • ASHN Manual Therapy Clinical Decision Assist Guide - Medical Necessity(Sign up to download.)
                                                • ASHN Medical Necessity Definition(Sign up to download.)

                                                  • Aetna

                                                • Aetna Chiropractic Policy Bulletin 2023-2024(Sign up to download.)

                                                  • Blue Cross Blue Shield

                                                • Blue Cross Blue Shield Florida Manual For Physicians And Providers - Chiropractic(Sign up to download.)
                                                • Blue Cross Blue Shield Horizon New Jersey(Sign up to download.)
                                                • Blue Cross Blue Shield Illinois Chiropractic Services Manual 2019-2020(Sign up to download.)
                                                • Blue Cross Blue Shield Minnesota Chiropractic Coding Policies And Guidelines(Sign up to download.)

                                                  • Cigna

                                                • Chiropractic Coverage Policy 2020(Sign up to download.)

                                                  • Evicore Chiropractic Guidelines

                                                • Evicore Chiropractic Services Guideline 2020(Sign up to download.)

                                                  • Optum Health

                                                • Optum Health CMT Reimbursement Policy(Sign up to download.)

                                                  • United Health Care

                                                • United Health Care - Chiropractic Manipulation Policy(Sign up to download.)

                                                  • Insurance Verification Form

                                                      • Insurance Verification Acupuncture(Sign up to download.)
                                                      • Insurance Verification Chiropractic(Sign up to download.)

                                                      Medicare

                                                          ABN

                                                        • ABN 2023 Instructions(Sign up to download.)
                                                        • ABN 2023 Update(Sign up to download.)
                                                        • ABN 2023 Update(Sign up to download.)
                                                        • ABN Large Print Update(Sign up to download.)
                                                        • ABN Large Print Update(Sign up to download.)
                                                        • ABN Spanish Large Print Update(Sign up to download.)
                                                        • ABN Spanish Large Print Update(Sign up to download.)
                                                        • ABN Spanish Update(Sign up to download.)
                                                        • ABN Spanish Update(Sign up to download.)

                                                          • Documentation

                                                        • Chiropractic Documentation(Sign up to download.)

                                                          • Outcome Assessments & Disability Indexes

                                                              Balance

                                                            • Balance Test - Tinetti(Sign up to download.)
                                                            • Berg Balance Scale(Sign up to download.)

                                                              • Concussion

                                                            • Acute Concussion Evaluation(Sign up to download.)

                                                              • Depression

                                                            • Depression Assessment(Sign up to download.)

                                                              • Extremities

                                                            • Disabilities Of The Shoulder And Hand(Sign up to download.)
                                                            • Lower Extremity Functional Scale(Sign up to download.)

                                                              • Gait

                                                            • Gait Assessment - Tinetti(Sign up to download.)

                                                              • Headache

                                                            • Headache Disability Index(Sign up to download.)

                                                              • Pain & Health Survey

                                                            • Fear Avoidance Behavior Questionnaire(Sign up to download.)
                                                            • Fear Avoidance Beliefs Questionnaire(Sign up to download.)
                                                            • General Pain Index(Sign up to download.)
                                                            • McGill Pain Questionnaire(Sign up to download.)
                                                            • McGill Short Form(Sign up to download.)
                                                            • Pain Scale With General Pain Index(Sign up to download.)
                                                            • Patient-specific-functional-scale(Sign up to download.)
                                                            • Picture Pain Disability(Sign up to download.)
                                                            • SF36 General Health Survey(Sign up to download.)
                                                            • SF36 Scoring(Sign up to download.)

                                                              • Pain and Function Scale Veterans

                                                            • DoD VA Pain Rating Scale(Sign up to download.)
                                                            • DoD VA Pain Supplemental Questions(Sign up to download.)

                                                              • Sleepiness

                                                            • Epworth Sleepiness Scale(Sign up to download.)

                                                              • Spanish

                                                            • ADL - Spanish(Sign up to download.)
                                                            • Low Back Oswestry - Spanish(Sign up to download.)
                                                            • Low Back Roland Morris - Spanish(Sign up to download.)
                                                            • Neck Oswestry Spanish(Sign up to download.)
                                                            • VA Pain Rating Scale - Spanish(Sign up to download.)

                                                              • Spine

                                                            • Copenhagen Neck Disability(Sign up to download.)
                                                            • Neck Disability Index(Sign up to download.)
                                                            • Neck Disability Scoring Method(Sign up to download.)
                                                            • Oswestry Low Back Disability Index(Sign up to download.)
                                                            • Oswestry Scoring Method(Sign up to download.)
                                                            • Roland Morris (Low Back)(Sign up to download.)

                                                              • TMJ

                                                            • TMJ Questionnaire(Sign up to download.)

                                                              • Superbill and Charge Slip

                                                                  • ChiropracticSuperbill2025(Sign up to download.)

                                                                  Treatment Guidelines

                                                                      ACOEM

                                                                    • Ankle-and-Foot-Disorders-Guideline(Sign up to download.)
                                                                    • Cervical-and-Thoracic-Spine-Disorders-Guideline(Sign up to download.)
                                                                    • Chronic-Pain-Guideline(Sign up to download.)
                                                                    • Elbow-Disorders-Guideline(Sign up to download.)
                                                                    • Hand-Wrist-and-Forearm-Disorders-Guideline-1(Sign up to download.)
                                                                    • Hip-and-Groin-Disorders-Guideline(Sign up to download.)
                                                                    • Initial-Approaches-to-Treatment-Guideline(Sign up to download.)
                                                                    • Low-Back-Disorders-Guideline(Sign up to download.)
                                                                    • Opioids-Guideline(Sign up to download.)
                                                                    • Shoulder-Disorders-Guideline(Sign up to download.)

                                                                      • Chronic and Non Acute Pain

                                                                    • Chronic Pain Disorder (searchable For Chiropractic)(Sign up to download.)
                                                                    • Non-Acute Pain Medical Treatment Guideline(Sign up to download.)

                                                                      • Complex Regional Pain Syndrome

                                                                    • Complex Regional Pain Syndrome Reflex Sympathetic Dystrophy (searchable For Chiropractic)(Sign up to download.)

                                                                      • Cumulative Trauma

                                                                    • Cumulative Trauma Conditions (searchable For Chiropractic)(Sign up to download.)

                                                                      • Extremities

                                                                    • Carpal Tunnel Medical Treatment Guideline(Sign up to download.)
                                                                    • Knee Injury Medical Treatment Guideline(Sign up to download.)
                                                                    • Lower Extremity Injury (searchable For Chiropractic)(Sign up to download.)
                                                                    • Shoulder Injury (searchable For Chiropractic)(Sign up to download.)
                                                                    • Shoulder Injury Medical Treatment Guideline(Sign up to download.)

                                                                      • Mercy Conference

                                                                    • Mercy Conference Guideline Chapter 8 Freqency And Duration Of Care(Sign up to download.)

                                                                      • Spine

                                                                    • Cervical Spine Injury (searchable For Chiropractic)(Sign up to download.)
                                                                    • Low Back Pain (searchable For Chiropractic)(Sign up to download.)
                                                                    • Mid And Low Back Injury Medical Treatment Guideline(Sign up to download.)
                                                                    • Neck Injury Medical Treatment Guideline(Sign up to download.)
                                                                    • Thoracic Outlet Syndrome (searchable For Chiropractic)(Sign up to download.)