(239) 541-3434

"Have your spine checked today!"

Below are links to our new patient paperwork forms. Just simply select the type of insurance you will be using for your treatment purposes and print out your forms. 

If, at any time, you have questions regarding the paperwork, please call the office or leave the item(s) in question blank and we will assist you during your initial visit.

Thank you for visiting barneschiropractic.net!

For Automobile Insurance purposes,

please print all 10 forms in the below document library:

Document Library

NameDescription
DocumentAuto Form 1Assignment_of_Benefits
DocumentAuto Form 2Attending_Physician_Report
DocumentAuto Form 3Consent_to_Disclose_form
DocumentAuto Form 4EMS_US
DocumentAuto Form 5Intake-_Auto
DocumentAuto Form 6Intake-General
DocumentAuto Form 7LOP-Notice_of_Dr_Lien
DocumentAuto Form 8PIP_Payout
DocumentAuto Form 9Release_of_Records
DocumentAuto Form 10HCFA

For No Insurance or General Health Insurance [i.e. Aetna, BCBS, United, etc] purposes, please print all 5 forms in the below document library:

Document Library

NameDescription
DocumentForm 1APPLICATION_FOR_TREATMENT
DocumentForm 2Consent_to_Disclose_form
DocumentForm 3EMS_US
DocumentForm 4Release_of_Records
DocumentForm 5HCFA