Forms and Insurance

New Patient Forms

Part 1 - Fill Out Online

Please complete and submit Part 1 of our new patient forms prior to your first appointment. If you are not able to complete the online form in advance, please arrive 10-15 minutes early to complete all forms.

Please note: Our online forms are compatible with iPhones and desktop computers, but may not be with Android phones.

Part 1 – Pediatric Patient (0-8 years)

Part 2 - PDF to fill out and sign

Please print out and complete Part 2 of our new patient forms. (You may complete digitally if you have the capability of signing digitally.)

If you are not able to complete both Part 1 and Part 2, please arrive 10-15 minutes early to complete all forms.

Part 2 – All Patients

Nurse Practitioner Appointments

Please complete these forms if you have have an appointment with our Nurse Practitioner.

Nurse Practitioner – For FemalesNurse Practitioner – For Males

HIPAA Form

Please review this HIPAA document prior to your first appointment. You'll have the chance to sign off and ask questions when you arrive.

Insurance Options

Capital Chiropractic & Rehabilitation Center accepts most major insurance plans and also offers a self-pay option to best accommodate patients’ access to whole-person wellness care.

To help you make the best choice about whether to use your insurance coverage or choose self-pay for your care here, please use the contact details below to contact your provider.

Ask them to verify how much coverage you have for chiropractic care, physical therapy, acupuncture/dry needling, soft tissue therapies, and nutritional counseling. Then record those details on our Insurance Verification Worksheet for your reference.

Please share a copy of your findings with us to minimize surprises for all of us as you seek care here.

Questions? We’d love to help. Please complete the Insurance Verification Worksheet and bring it with you to your appointment!

Insurance Verification Worksheet

Auto Accident Patients

To verify your insurance coverage for treatment, please use our Auto Insurance Verification Worksheet linked below.

Auto Insurance Verification Worksheet

Major Insurance Companies’ Contact Information

Amerigroup

Health Partners

Medica

UnitedHealthcare

  • Website
  • Phone: Call the number on your Health Plan ID Card for the most direct service help.

Wellmark 

Self-Pay Option

We use The Wellness Group to offer a self-pay option that simplifies and streamlines patient access to care. Patients who choose this option typically are uninsured, underinsured, or prefer the reliable, simple rates and full access to all of our clinic’s treatments. To learn more about this option, just ask at the front desk.