Language
  • English (US)
  • Image
  • HEALTH INSURANCE & PAYMENT AGREEMENT FORM

    (you will need a front and back copy of your insurance card)
  •  - -
    Pick a Date
  •  - -
    Pick a Date

  •  -
  • SERVICES REQUESTED

    (Submit your insurance requests at least 4 weeks before your estimate start of care date for priority consideration. Please note that One-time Injections (i.e. Trigger Shots) ARE NOT billed directly to insurance AND those requesting these services should not use this form.)

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  •  :
    Until
     :
  • Health Insurance Plan Type

  • Primary Insurance Information

  •  - -
    Pick a Date


  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Secondary Insurance Information

    (if not applicable, then skip to next section)
  •  - -
    Pick a Date


  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Additional Information

    (Please include any additional information that you feel will help CNS staff in verifying your insurance benefits.)
  • Terms and Conditions

  • I authorize the release of any medical or other information necessary to process an insurance claim. I understand that CNS will diligently attempt to get accurate information regarding my health insurance benefits. I will not hold CNS liable for insurance nonpayment due to misquoted benefits. I acknowledge that I am responsible to know and understand my benefits plan. If CNS accepts me as a client, then CNS will file my insurance claims if in-network for me as a courtesy. I am ultimately responsible for any co-pay(s) and all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits be paid to CNS.

  • Clear
  •  - -
    Pick a Date
  •  
  • Should be Empty: