Pediatric History Form

Disclaimer About Infant Chiropractic Care: 

For children under 1-2 years old, chiropractic care is often seen by insurance companies as "investigational" treatment. Whether it is a manipulation or just muscle work, there are many times when we send claims to the insurance provider for an infant's treatment and it comes back  uncovered regardless of the plans limits and benefits for chiropractic care. This can be frustrating as we and you know you child needs this care in order to function and keep growing in their best healthy selves and you may have even been referred by your pediatrician! We do our best to appeal these decisions by the insurance companies but a lot of the time they will not budge on their decision. It does help to have a referral from a pediatrician on file for the times when we need to appeal these decisions, so if you do have one please let us know and we can get that saved to your child's file. If the decision to not cover services is upheld by the insurance company there is not much more we can do and the care will be subject to the out of pocket rates. 

It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

In Network

Anthem Regence 

BCBS

Moda

Providence

Kaiser Physician Referred (You need a referral from your Kaiser PCP before your appointment if you have this plan)

American Specialty Health

Pacific Source

HealthNet

*Medicare (as of 11/19/2024 we are not currently accepting any new Medicare Patients. This will update as we are ready to accept new Medicare Patients) 

CHP (Kaiser Self-Referred)

Cigna

We are NOT IN NETWORK with Medicaid (This includes Oregon Health Plan, Healthshare of Oregon and any other entities funded by Medicaid. Please double check that your insurance plan is not through Medicaid as they will sometimes send you a card that says "Kaiser" (for example) but the plan is still administered through Medicaid and we cannot bill them.)

If your insurance plan is not listed in this table we are likely out of network and you can expect to pay out of pocket for services rendered. We do not send claims to out of network insurers but when you pay out of pocket we are happy to provide you with a superbill to submit to your out of network insurer for any reimbursement they might give you for out of network services.