Workman’s Comp Tools > Insurance Verification Type > Workman's Comp Today's Date* Date Format: MM slash DD slash YYYY Patient Name* First Last Phone*Email* Clinic*Choose a ClinicBalanced Living ChiropracticComplete Balance ChiropracticCoulee HealthErickson ChiropracticHonchel ChiropracticKaizen ChiropracticNemitz ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksRichard Wilson DCRiverside ChiropracticWeber ChiropracticWW AppletonWW BeavertonWW BloomingtonWW Burr RidgeWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Green BayWW JacksonvilleWW LargoWW LouisvilleWW MequonWW North PhoenixWW PensacolaWW RockfordWW SpringWW WaukeshaWW Woodbury (Empower Health)Workman's Comp InsuranceName of InsuranceDoes this patient have Workman's Comp Insurance to bill to?Yes, patient's account is set for billing to this insurance. Insurance company sends payment to clinic.NoAdditional comments?Attorney InformationHas patient retained an attorney?YesNoName of AttorneyAdditional InformationWe will work with this attorney to supply them with the statements and records they need as they seek a settlement for this workman's comp claim.NotesDisclaimer When we call on a patient's auto insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual coverage when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient must understand that their insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact benefits.PhoneThis field is for validation purposes and should be left unchanged.
