Useful Forms

Please select from the list below for the appropriate form.  Each form will open in a separate window which you can print for your convenience.

New Patient forms for Chiropractic Care

  1. Fast Track Scheduling: This form can be used by other physicians/medical facilities to refer patients to any of our four doctors at Burkhart & Chapp Chiropractic.
  2. One Time Authorization Agreement:  If you have Medicare insurance and are a new patient to our practice, please complete this form which allows Medicare to send their payments for your services directly to our practice.
  3. Medicare Advanced Beneficiary Notice (ABN):  This is used for Medicare patients when they are receiving services which will not be covered (i.e. X-rays, Exams, Therapies).  By having patients sign this, they are agreeing that they have been made aware that not all of the services they are receiving in our office that day will be covered by Medicare.
  4. New Patient Initial Evaluation Intake Form:  Please complete this form prior to the first time you come into our office for services and are either paying cash or having us bill your health insurance for the services you will receive.
  5. New Patient Initial Evaluation Form FOR MINORS and RE-ESTABLISHED PATIENTS: Please complete this form prior to the first time you come into our office for services and are either paying cash or having us bill your health insurance for the services you will receive.
  6. Automobile Accident Evaluation Intake Form:  Please complete this form prior to the first time you come into our office, if you will be receiving services due to an auto accident that will be billed to an auto insurance company.
  7. Records Release FROM Burkhart & Chapp: This form needs to be signed by the patient in order for us to release x-rays and other records from our office to other health care providers.
  8. Records Release TO Burkhart & Chapp: This form needs to be signed by the patient in order for other healthcare providers to release records to our office.
  9. HIPPA form: This form needs to be signed by the patient indicating that they have been made aware that their information will not be shared without their consent.  Under HIPAA guidelines, there are also other rules and regulations involving the patient’s legal obligation to pay their copays or deductibles.
  10. FABQ form: This form gives the doctor an understanding of how the patient’s pain affects their activities of daily living.  There are two sections to the FABQ, the first being related to general daily activities and the second primarily related to questions about work.  The patient should indicate how much they agree with each question or statement.