Patient Forms

Please use the following links to print and fill out our insurance coverage and patient health history forms.



Group or Individual Insurance

We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk has years of experience and will be happy to assist you.

Patients Without Insurance

An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

"On the Job" Injury (Worker's Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

Personal Injury or Automobile Accidents

Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.

Beacon Health

Phillips Chiropractic Acupuncture is now a Designated Wellness Network Provider for the Beacon Health Wellness Network. Beacon health has established a credentialed and discounted network or community providers to provide more wellness opportunities for EMHS employees statewide.


Now you can use your CareCredit healthcare credit card to pay for regular chiropractic appointments and adjustments. CareCredit helps you pay for out-of-pocket healthcare expenses to help manage health and wellness a costs not covered by insurance.


We do follow Medicare fee guidelines, however, we are non-participating. You will be provided with a detailed receipt with all services provided during your visit that you may submit Medicare for reimbursement , which for Chiropractors is ONLY manual manipulation of the spine.

Secondary Insurance

Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.
(207) 922-2321
(207) 922-2492
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