Chiropractic Treatment Plan PDF Form - FormsPal

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.

Question	Answer
Form Name	Chiropractic Treatment Plan Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	69
Avg. time to fill out	14 min 3 sec
Other names	chiropractic plan of care forms, chiropractic treatment plan forms, chiropractic treatment plan form, chiropractic plan form

12

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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Step 1: Press the orange "Get Form Now" button on this page.

Step 2: So, you are on the document editing page. You may add content, edit present details, highlight particular words or phrases, place crosses or checks, add images, sign the file, erase unwanted fields, etc.

The following areas are what you are going to fill out to get the prepared PDF file.

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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