{"id":45,"date":"2021-06-17T22:06:52","date_gmt":"2021-06-17T22:06:52","guid":{"rendered":"https:\/\/backalleychiropractic.com\/?page_id=45"},"modified":"2025-12-31T13:54:31","modified_gmt":"2025-12-31T20:54:31","slug":"forms","status":"publish","type":"page","link":"https:\/\/backalleychiropractic.com\/?page_id=45","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n

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<\/a> with any questions about which forms you should download.<\/p>\n\n\n\n

1) If necessary, install AdobeReader\u00ae to your computer, click here<\/a> t<\/span><\/span><\/a><\/mark><\/mark><\/strong>o 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.<\/p>\n\n\n\n

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Contact the front desk if you are not certain which forms are required for your appointment.<\/p>\n\n\n\n

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Insured\/Self-pay\/Medicare Advantage<\/strong><\/p>\n\n\n\n

New Patient with Insurance<\/a><\/div>\n\n\n\n
New Patient Self-pay<\/a><\/div>\n\n\n\n
Additional Chief Complaints<\/a><\/div>\n\n\n\n
Re-Exam Patient with Insurance<\/a><\/div>\n\n\n\n
Re-Exam Patient Self-pay<\/a><\/div>\n\n\n\n
Update Forms for Insured<\/a><\/div>\n\n\n\n
Update Forms for Self-pay<\/a><\/div>\n\n\n\n
Minor Consent Form<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

Medicare Part B Patient<\/strong><\/p>\n\n\n\n

New Patient with Medicare Part B<\/a><\/div>\n\n\n\n
Additional Chief Complaints<\/a><\/div>\n\n\n\n
Re-Exam for Medicare Part B<\/a><\/div>\n\n\n\n
Update Forms for Medicare Part B<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

Auto Accident\/Personal Injury Patient<\/strong><\/p>\n\n\n\n

Personal Injury Patient Forms<\/a><\/div>\n\n\n\n
Additional Chief Complaints for Personal Injury<\/a><\/div>\n\n\n\n

Also complete each of the applicable forms:<\/p>\n\n\n\n

Arm, Shoulder, Hand Pain questionnaire<\/a><\/div>\n\n\n\n
Headache questionnaire<\/a><\/div>\n\n\n\n
Low Back Pain questionnaire<\/a><\/div>\n\n\n\n
Lower Extremity Pain questionnaire<\/a><\/div>\n\n\n\n
Neck Pain questionnaire<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

Work Comp Patient<\/strong><\/p>\n\n\n\n

Work Comp Patient Forms<\/a><\/div>\n\n\n\n
Workers Report Of Injury*<\/a><\/div>\n\n\n\n
Workers & Physicians Report Of Injury**<\/a><\/div>\n\n\n\n

Also complete each of the applicable forms:<\/p>\n\n\n\n

Arm, Shoulder, Hand Pain questionnaire<\/a><\/div>\n\n\n\n
Headache questionnaire<\/a><\/div>\n\n\n\n
Low Back Pain questionnaire<\/a><\/div>\n\n\n\n
Lower Extremity Pain questionnaire<\/a><\/div>\n\n\n\n
Neck Pain questionnaire<\/a><\/div>\n\n\n\n
<\/div>\n<\/div>\n\n\n\n
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General Forms<\/strong><\/p>\n\n\n\n

Insurance Coverage Form<\/a><\/div>\n\n\n\n
Medicare Coverage Form<\/a><\/div>\n\n\n\n
Patient Demographic Update<\/a><\/div>\n\n\n\n
Election to Self-pay Form<\/a><\/div>\n\n\n\n
Credit Card Authorization<\/a><\/div>\n\n\n\n
Physician to Physician Records Request<\/a><\/div>\n\n\n\n
Patient Authorization for Protected Health Information<\/a><\/div>\n\n\n\n
Social Media Consent<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

PiezoWave2 MyACT<\/strong><\/p>\n\n\n\n

PiezoWave Brochure<\/a><\/div>\n\n\n\n
PiezoWave Patient Information<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

Massage Therapy<\/strong><\/p>\n\n\n\n

Massage Therapy Policy<\/a><\/div>\n\n\n\n
Massage Therapy Intake<\/a><\/div>\n\n\n\n
Minor Consent for Massage Therapy<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

Insurance Specific<\/strong><\/p>\n\n\n\n

Complete the applicable form(s) for your plan only<\/em> if directed to:<\/p>\n\n\n\n

UnitedHealthcare AARP Medicare Advantage plans<\/p>\n\n\n\n

OPTUM Patient Summary<\/a><\/div>\n\n\n\n
OPTUM Back Assessment<\/a><\/div>\n\n\n\n
OPTUM Neck Assessment<\/a><\/div>\n\n\n\n
OPTUM Arm, Shoulder, Hand Assessment<\/a><\/div>\n\n\n\n
OPTUM Lower Extremity Assessment<\/a><\/div>\n\n\n\n
OPTUM Keele Start form<\/a><\/div>\n\n\n\n
OPTUM Patient Billing Acknowledgement<\/a><\/div>\n\n\n\n

BCBS Arizona, Cigna, Ambetter plans<\/p>\n\n\n\n

ASH Initial Health Status<\/a><\/div>\n\n\n\n
ASH Patient Progress<\/a><\/div>\n\n\n\n

Humana Choice Care Network plans<\/p>\n\n\n\n

Humana PSFS<\/a><\/div>\n\n\n\n
<\/div>\n\n\n\n

HIPAA Forms<\/strong><\/p>\n\n\n\n

Notice of Privacy Practices<\/a><\/div>\n<\/div>\n<\/div>\n\n\n\n

*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.<\/em>
**Please only complete top portion of form including signature and date.<\/p>\n","protected":false},"excerpt":{"rendered":"

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\u00ae to your computer, click here to download. 2) Download […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":915,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"template-full-width.php","meta":{"footnotes":""},"class_list":["post-45","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/pages\/45","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=45"}],"version-history":[{"count":151,"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/pages\/45\/revisions"}],"predecessor-version":[{"id":4203,"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/pages\/45\/revisions\/4203"}],"up":[{"embeddable":true,"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=\/wp\/v2\/pages\/915"}],"wp:attachment":[{"href":"https:\/\/backalleychiropractic.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=45"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}