Document Library

1500 Claim form

      • 1500 02-12 Version Fill In The Blank With Calculations(Log in or Sign up to download.)
      • 1500 Claim Form Instruction Manual 2012 02-v2(Log in or Sign up to download.)

      CPT

          Correpondence Letters

              Denial of E&M with CMT

            • Denial Of E&M Code(Log in or Sign up to download.)
            • Denial Of E&M Code(Log in or Sign up to download.)
            • Denials per CCI Edits

            • 97110-97124 Denial When Billed With CMT(Log in or Sign up to download.)
            • 97110-97124 Denial When Billed With CMT(Log in or Sign up to download.)
            • 97140 Denial With CMT Aetna Et Al(Log in or Sign up to download.)
            • 97140 Denial With CMT Aetna Et Al(Log in or Sign up to download.)
            • Insurance Disputing Fees

            • Usual Customary And Reasonable Fee Reduction(Log in or Sign up to download.)
            • Usual Customary And Reasonable Fee Reduction(Log in or Sign up to download.)
            • Insurance requesting a refund

            • Insurance Requesting A Refund, Extended Response(Log in or Sign up to download.)
            • Insurance Requesting A Refund, Extended Response(Log in or Sign up to download.)
            • Insurance Requesting A Refund(Log in or Sign up to download.)
            • Insurance Requesting A Refund(Log in or Sign up to download.)
            • Maintenance and Medical Necessity Denials

            • Denial Of 97014 As Experimental(Log in or Sign up to download.)
            • Denial Of 97014 As Experimental(Log in or Sign up to download.)
            • Maintenance Care Denial(Log in or Sign up to download.)
            • Maintenance Care Denial(Log in or Sign up to download.)
            • Patient Collection

            • Patient Late Pay When They Receive The Check(Log in or Sign up to download.)
            • Patient Late Pay When They Receive The Check(Log in or Sign up to download.)
            • Patient Late Pay When They Receive The Check And Do Not Want To Pay In Full(Log in or Sign up to download.)
            • Patient Late Pay When They Receive The Check And Do Not Want To Pay In Full(Log in or Sign up to download.)
            • Patient Late Pay(Log in or Sign up to download.)
            • Patient Late Pay(Log in or Sign up to download.)
            • Personal Injury

            • Attorney Holding Med Pay(Log in or Sign up to download.)
            • Attorney Holding Med Pay(Log in or Sign up to download.)
            • Attorney Late Payment With Signed Lien(Log in or Sign up to download.)
            • Attorney Late Payment With Signed Lien(Log in or Sign up to download.)
            • Attorney Status Of Claim(Log in or Sign up to download.)
            • Attorney Status Of Claim(Log in or Sign up to download.)
            • Attorney Cover Letter With Lien(Log in or Sign up to download.)
            • Attorney Cover Letter With Lien(Log in or Sign up to download.)
            • Attorney Negotation To Reduce Settlement Rejection(Log in or Sign up to download.)
            • Attorney Negotation To Reduce Settlement Rejection(Log in or Sign up to download.)
            • Attorney Not Paying Settled Claim(Log in or Sign up to download.)
            • Attorney Not Paying Settled Claim(Log in or Sign up to download.)
            • Attorney Paying Reduced Amount Rejection(Log in or Sign up to download.)
            • Attorney Paying Reduced Amount Rejection(Log in or Sign up to download.)
            • Deposition Expert Witness Fees(Log in or Sign up to download.)
            • Deposition Expert Witness Fees(Log in or Sign up to download.)
            • Excess Med Pay HMO Primary(Log in or Sign up to download.)
            • Excess Med Pay HMO Primary(Log in or Sign up to download.)
            • Excess Med Pay No Primary Health Insurance(Log in or Sign up to download.)
            • Excess Med Pay No Primary Health Insurance(Log in or Sign up to download.)
            • Low Property Damage Explanation(Log in or Sign up to download.)
            • Low Property Damage Explanation(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim 2(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim 2(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim(Log in or Sign up to download.)
            • Patient Late Payment Of Settled Claim(Log in or Sign up to download.)
            • Termination of PPO Contract

            • Termination Of PPO Contract(Log in or Sign up to download.)
            • Termination Of PPO Contract(Log in or Sign up to download.)
            • Timely Filing Dispute

            • Timely Filing Dispute(Log in or Sign up to download.)
            • Timely Filing Dispute(Log in or Sign up to download.)
            • Withdrawal from care

            • Withdrawal From Care(Log in or Sign up to download.)
            • Withdrawal From Care(Log in or Sign up to download.)
            • Documentation

                  • Documentation Of Timed Therapeutic Services(Log in or Sign up to download.)
                  • Medicare Chiropractic Documentation(Log in or Sign up to download.)

                  External Causes of Injury ICD9 & ICD10 Codes

                      • E Codes ICD9 External Causes Of Injury(Log in or Sign up to download.)
                      • V, W, X, Y, & Z Codes ICD 10 Morbidity & Health Status Codes(Log in or Sign up to download.)

                      Financial Agreements

                          Credit Card Authorization

                        • Credit Card Authorization For Past Due Payments(Log in or Sign up to download.)
                        • General

                        • Financial Policy & Agreement (PDF)(Log in or Sign up to download.)
                        • Financial Policy & Agreement (editable)(Log in or Sign up to download.)
                        • Health Insurance Chiropractic (PDF)(Log in or Sign up to download.)
                        • Health Insurance Chiropractic (editable)(Log in or Sign up to download.)
                        • Hardship

                        • Financial Hardship Agreement (PDF)(Log in or Sign up to download.)
                        • Financial Hardship Agreement (editable)(Log in or Sign up to download.)
                        • Medicare

                        • Medicare Explanation Of Benefits, Chiropractic (PDF)(Log in or Sign up to download.)
                        • Medicare Explanation Of Benefits, Chiropractic (editable)(Log in or Sign up to download.)
                        • Personal Injury

                        • Personal Injury Financial Agreement (PDF)(Log in or Sign up to download.)
                        • Personal Injury Financial Agreement (editable)(Log in or Sign up to download.)
                        • Forms

                              Assignment of Benefits

                            • Assignment Of Benefits(Log in or Sign up to download.)
                            • Examination

                            • Examination Report (single Page)(Log in or Sign up to download.)
                            • Orthopedic And Neurological Examination (2 Pages)(Log in or Sign up to download.)
                            • Review Of Systems(Log in or Sign up to download.)
                            • History, Consultation & Examination

                            • Case History Including Accident Information (2 Pages)(Log in or Sign up to download.)
                            • History, Consultation & Examination (4 Pages)(Log in or Sign up to download.)
                            • History, Examination Detailed (6 Pages) Editable(Log in or Sign up to download.)
                            • History, Examination Detailed (6 Pages)(Log in or Sign up to download.)
                            • Patient History Update(Log in or Sign up to download.)
                            • Personal Injury Questionnaire(Log in or Sign up to download.)
                            • Personal Injury Lien

                            • Notice Of Doctors Lien(Log in or Sign up to download.)
                            • SOAP & Daily Notes

                            • Patient Treatment Card With SOAP (5 Pages)(Log in or Sign up to download.)
                            • SOAP With Explanation & Abbrevition Key (3 Pages)(Log in or Sign up to download.)
                            • Treatment Card With Notes (2 Pages)(Log in or Sign up to download.)
                            • Treatment Notes, Single Page(Log in or Sign up to download.)
                            • HCPCS Orthotics and DME Common Codes

                                  HIPAA

                                      • Business Associate Agreement Editable(Log in or Sign up to download.)

                                      Informed Consent

                                          • Informed Consent To Chiropractic Treatment (PDF)(Log in or Sign up to download.)
                                          • Informed Consent To Chiropractic Treatment (editable)(Log in or Sign up to download.)

                                          Insurance Chiropractic Coverage Policies

                                              ASHN

                                            • ASHN Manual Therapy Clinical Decision Assist Guide - Medical Necessity(Log in or Sign up to download.)
                                            • ASHN Medical Necessity Definition(Log in or Sign up to download.)
                                            • Aetna

                                            • Aetna Chiropractic Policy Bulletin 0107 - ICD10 -1(Log in or Sign up to download.)
                                            • Blue Cross Blue Shield

                                            • Blue Cross Blue Shield Florida Manual For Physicians And Providers - Chiropractic(Log in or Sign up to download.)
                                            • Blue Cross Blue Shield Horizon New Jersey(Log in or Sign up to download.)
                                            • Blue Cross Blue Shield Minnesota Chiropractic Coding Policies And Guidelines(Log in or Sign up to download.)
                                            • Cigna

                                            • Cigna Chiropractic Care Coverage 0267 2015-2016(Log in or Sign up to download.)
                                            • Optum Health United Health Care

                                            • Optum Health (United Health Care) CMT Reimbursement Policy(Log in or Sign up to download.)
                                            • Insurance Verification Form

                                                  • Insurance Verification Chiropractic(Log in or Sign up to download.)

                                                  Medicare

                                                      ABN

                                                    • ABN English 2020v508 Updated 2017(Log in or Sign up to download.)
                                                    • ABN English 2020v508 Updated 2017(Log in or Sign up to download.)
                                                    • ABN Spanish 2020 V508 Updated 2017(Log in or Sign up to download.)
                                                    • ABN Spanish 2020 V508 Updated 2017(Log in or Sign up to download.)
                                                    • ABN-Form-Instructions Updated 2017(Log in or Sign up to download.)
                                                    • Documentation

                                                    • Chiropractic Documentation(Log in or Sign up to download.)
                                                    • PQRS

                                                    • 2015 PQRS Implementation Guide(Log in or Sign up to download.)
                                                    • Chiropractic PQRS 2015(Log in or Sign up to download.)
                                                    • Outcome Assessments & Disability Inexes

                                                          Balance

                                                        • Balance Test - Tinetti(Log in or Sign up to download.)
                                                        • Berg Balance Scale(Log in or Sign up to download.)
                                                        • Concussion

                                                        • Acute Concussion Evaluation(Log in or Sign up to download.)
                                                        • Depression

                                                        • Depression Assessment(Log in or Sign up to download.)
                                                        • Extremities

                                                        • Disabilities Of The Shoulder And Hand(Log in or Sign up to download.)
                                                        • Lower Extremity Functional Scale(Log in or Sign up to download.)
                                                        • Gait

                                                        • Gait Assessment - Tinetti(Log in or Sign up to download.)
                                                        • Headache

                                                        • Headache Disability Index(Log in or Sign up to download.)
                                                        • Pain & Health Survey

                                                        • Fear Avoidance Behavior Questionnaire(Log in or Sign up to download.)
                                                        • Fear Avoidance Beliefs Questionnaire(Log in or Sign up to download.)
                                                        • General Pain Index(Log in or Sign up to download.)
                                                        • McGill Pain Questionnaire(Log in or Sign up to download.)
                                                        • McGill Short Form(Log in or Sign up to download.)
                                                        • Pain Scale With General Pain Index(Log in or Sign up to download.)
                                                        • Patient-specific-functional-scale(Log in or Sign up to download.)
                                                        • Picture Pain Disability(Log in or Sign up to download.)
                                                        • SF36 General Health Survey(Log in or Sign up to download.)
                                                        • SF36 Scoring(Log in or Sign up to download.)
                                                        • Sleepiness

                                                        • Epworth Sleepiness Scale(Log in or Sign up to download.)
                                                        • Spine

                                                        • Copenhagen Neck Disability(Log in or Sign up to download.)
                                                        • Neck Disability Index(Log in or Sign up to download.)
                                                        • Neck Disability Scoring Method(Log in or Sign up to download.)
                                                        • Oswestry Low Back Disability Index(Log in or Sign up to download.)
                                                        • Oswestry Scoring Method(Log in or Sign up to download.)
                                                        • Roland Morris (Low Back)(Log in or Sign up to download.)
                                                        • TMJ

                                                        • TMJ Questionnaire(Log in or Sign up to download.)
                                                        • Superbill and Charge Slip

                                                              Treatment Guidelines

                                                                  ACOEM

                                                                • Ankle-and-Foot-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Cervical-and-Thoracic-Spine-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Chronic-Pain-Guideline(Log in or Sign up to download.)
                                                                • Elbow-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Hand-Wrist-and-Forearm-Disorders-Guideline-1(Log in or Sign up to download.)
                                                                • Hip-and-Groin-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Initial-Approaches-to-Treatment-Guideline(Log in or Sign up to download.)
                                                                • Low-Back-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Opioids-Guideline(Log in or Sign up to download.)
                                                                • Shoulder-Disorders-Guideline(Log in or Sign up to download.)
                                                                • Chronic and Non Acute Pain

                                                                • Chronic Pain Disorder (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Non-Acute Pain Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Complex Regional Pain Syndrome

                                                                • Complex Regional Pain Syndrome Reflex Sympathetic Dystrophy (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Cumulative Trauma

                                                                • Cumulative Trauma Conditions (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Extremities

                                                                • Carpal Tunnel Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Knee Injury Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Lower Extremity Injury (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Shoulder Injury (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Shoulder Injury Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Mercy Conference

                                                                • Mercy Conference Guideline Chapter 8 Freqency And Duration Of Care(Log in or Sign up to download.)
                                                                • Spine

                                                                • Cervical Spine Injury (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Low Back Pain (searchable For Chiropractic)(Log in or Sign up to download.)
                                                                • Mid And Low Back Injury Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Neck Injury Medical Treatment Guideline(Log in or Sign up to download.)
                                                                • Thoracic Outlet Syndrome (searchable For Chiropractic)(Log in or Sign up to download.)