PLEASE answer every question. If it doesn’t apply, write “N/A” so that I know you saw it. If you are not sure how to answer, make sure you arrive early enough to get clarification and finish these forms before your appointment.
PLEASE do not fold or staple your forms. If you are able to, please print them on both sides of the paper. These forms will be scanned and shredded once you have checked in for your visit.
Read down the list – more than one category may apply. Download each section that applies to you, print, and fill out.
Step One – Select Your Situation
Step Two – Select Your Coverage Type
***IF YOU DO NOT HAVE CIGNA, MEDICARE, MEDICARE, OR CHP, NO FURTHER PAPERWORK IS NEEDED***
Step Three – Select Your Body Part(s)
Based on the body chart below, click the number corresponding to the primary area in which you are having pain: