Forms & Links

We offer copies of our paperwork online to save you time.  If you would prefer, you can always arrive 15 minutes early for your scheduled appointment to complete the paperwork in our office.

Here are links to our forms so you can fill out paperwork and bring with you to your appointment or submit via email at comcarechiro@gmail.com.  Please see below the list of forms for instructions on completion.

The following forms need to be completed by ALL NEW PATIENTS:

New Patient Intake Form

Health Questionnaire

Privacy Policy (only need to read, print if you would like paper copy for YOUR records only)

Privacy Policy Signature Page (to be submitted acknowledging you read the Privacy Policy)

HIPAA Contact & Personal Release

The following forms need to be completed if treating under MEDICARE ONLY:

Advanced Beneficiary Notice

Neck Index (for neck and headache complaints)

Low Back Index (for low back complaints only)

If you have both neck and low back complaints, please complete both index forms.

The following forms need to be completed if treating under WORKERS’ COMPENSATION ONLY:

Workers’ Compensation Questionnaire

Responsibility of Payment Form

Neck Index (for neck and headache complaints)

Low Back Index (for low back complaints only)

If you have both neck and low back complaints, please complete both forms.

The following forms need to be completed if treating under NO-FAULT or Auto-Accident ONLY:

Auto-Accident Questionnaire

Assignment of Benefits Form

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To use forms, please click on the link above for all appropriate forms.  When new window(s) open, please download/save or print file.

At this point you may print paper copies to complete with pen and bring to your appointment.

Or, you can complete and submit electronically by following these instructions:

Upon opening file (use of Adobe Acrobat Reader is necessary), click on “Sign” in the upper right hand corner, then click “Add Text”, click where you would like to add text and type.  For questions which require a selection, please click on the “Highlight Text” button in the top menu bar, then use your mouse to highlight the appropriate answer.

Save the completed forms.

Email the completed forms as attachments to comcarechiro@gmail.com

If you have any questions along the way, feel free to call the office at 580-3577.

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