ADDRESS

2060 E Tangerine Rd Ste 182
Oro Valley, AZ 85755-6251

Patient Forms

The Back Alley Chiropractic & Massage offers our patient forms online so you can print and complete in the convenience of your own home or office. Contact our office at (520) 877-2666 with any questions about which forms you should download.

1) If necessary, install AdobeReader® to your computer, click here to download. 2) Download the applicable forms, print, fill in the required information in full, and sign each page. 3) Bring the completed forms with you to your appointment or fax them to us at (520) 877-9183.

Patient Insured or Selfpay (non-medicare)

New Patient Forms – if you have Medicare Part B please do not complete these forms
Additional Chief Complaints
Minor Consent
Re-Exam Patient Forms

Medicare Part B Patient

New Medicare Part B Patient Forms – if you do not have Medicare Part B please do not complete these forms
Additional Chief Complaints
Re-Exam Medicare Part B Patient Forms – if you do not have Medicare Part B please do not complete these forms

Auto Accident/Personal Injury Patient

Personal Injury Intake
Additional Chief Complaints for Personal Injury

Also complete each of the applicable forms:

Arm, Shoulder, Hand Pain questionnaire
Headache questionnaire
Low Back Pain questionnaire
Lower Extremity Pain questionnaire
Neck Pain questionnaire

Work Comp Patient

Work Comp Patient Forms
Workers Report Of Injury*

Also complete each of the applicable forms:

Arm, Shoulder, Hand Pain questionnaire
Headache questionnaire
Low Back Pain questionnaire
Lower Extremity Pain questionnaire
Neck Pain questionnaire

HIPAA Forms

Notice of Privacy Practices

General Forms

Update Form
Update Form for Medicare Patient
Insurance Coverage Form
Medicare Coverage Form
Minor Consent
Credit Card Authorization
Physician to Physician Records Request
Social Media Consent

PiezoWave2 MyACT

PiezoWave Brochure
PiezoWave Patient Information
PiezoWave Consent

Massage Therapy

Massage Therapy Policy
Massage Therapy Intake
Minor Consent for Massage Therapy

Insurance Specific

Complete the applicable form(s) for your plan only if directed to:

UnitedHealthcare AARP Medicare Advantage plans

OPTUM Patient Summary
OPTUM Back Assessment
OPTUM Neck Assessment
OPTUM Arm, Shoulder, Hand Assessment
OPTUM Lower Extremity Assessment
OPTUM Keele Start form
OPTUM Patient Billing Acknowledgement

BCBS Arizona, Cigna, Ambetter plans

ASH Initial Health Status
ASH Patient Progress

Humana Choice Care Network plans

Humana PSFS

*If you have completed a Worker’s Report Of Injury form with your Employer please bring a copy with you to your appointment, otherwise complete this form in full.