Chiropractic Treatment Plan Form PDF Details

Chiropractic care is a common form of treatment for back and neck pain. A chiropractic treatment plan form can help you track your progress and ensure that you are receiving the most effective care possible. A well-crafted chiropractic treatment plan should include information about your medical history, current condition, and goals for treatment. Working with a chiropractor can be an effective way to manage chronic pain and improve your overall quality of life. By completing a treatment plan form, you can be sure that you are getting the most out of your chiropractic care.

Listed here, you'll find some information regarding chiropractic treatment plan form PDF. You will have the approximate time it will take you to fill in the form and a few extra details.

QuestionAnswer
Form NameChiropractic Treatment Plan Form
Form Length1 pages
Fillable?Yes
Fillable fields69
Avg. time to fill out14 min 3 sec
Other nameschiropractic plan of care forms, chiropractic treatment plan forms, chiropractic treatment plan form, chiropractic plan form

Form Preview Example

P.O. Box 1368 • Lilburn, GA 30048 ph 770.455.0040 • toll free 888.635.0459 • fax 678.990.0025

CHIROPRACTIC TREATMENT PLAN FORM

(Please Print or Type Clearly)

Note: If all information is not filled out completely and accurately this form will be returned without authorization.

Date: _____________________

PATIENT INFORMATION

Last:

Network Doctor’s Name: _________________________________

Treating Doctor: _________________________________________

First:

Middle:

DOB:

 

 

 

Member ID #

Suffix

Height

Weight

PROVIDER INFORMATION

Provider Name

Federal Tax ID #

Phone

Fax

NPI #

Prior Diagnoses: List primary diagnoses for which you have treated this patient in the last 12 months.

Diagnoses (Past 12 Months)

ICD9 Code

# of Treatments

From (Start Date)

To (End Date)

_______________________

______.___

________

__________

__________

_______________________

______.___

________

__________

__________

_______________________

______.___

________

__________

__________

 

 

 

 

 

 

Current Diagnoses

ICD9 Code

 

Patient Type (check one)

 

_______________________

______.___

 

 

 

 

 

 

_______________________

______.___

 

New to your office

 

_______________________

______.___

 

Established Patient, New Injury

 

 

 

 

 

 

 

 

Date Current Condition Began

First Visit for Current Condition

 

Established Patient, New Episode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Established Patient, Continuing Care

Start date for THIS authorization

 

 

 

 

 

 

 

 

 

 

 

 

Number of additional visits requested: _____ over _____days or _____ weeks.

 

 

 

 

 

 

 

 

 

 

 

 

1.Etiology or cause of current condition? _____________________________________________________

2.What is the patient primary complaint? _____________________________________________________

3.

Have you completed the acute phase of treatment? _______

Has the patient been compliant? ________

4.

Initial Pain Level (Circle one)

1

2

3

4

5

6

7

8

9

10

5.

Current Pain Level (Circle one)

1

2

3

4

5

6

7

8

9

10

6.Percentage of recovery to date? ____________

7.Is there anything about this case that makes it unusual or that may hinder your progress? ____________

___________________________________________________________________________________

Signature: _______________________________________

Print Name & Title (if other than provider): ______________________________________

How to Edit Chiropractic Treatment Plan Form Online for Free

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chiropractic plan of care forms gaps to fill in

Fill in the Current Diagnoses , First Visit for Current Condition,  Established Patient,  Established Patient,  Established Patient, Start date for THIS authorization, Number of additional visits, Initial Pain Level (Circle one) –, Is there anything about this case, Signature: , and Print Name & Title (if other than areas with any content that is required by the application.

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