1st Visit

Thank you for choosing Chinatown Physical Medicine & Rehab for your medical needs

Please download these forms, fill them out & bring them with you to expedite your visit.

(Click on a link below and once a new page opens up, click on the link again):


We are committed to providing you with the best possible care. This information is designed to guide you through the rapidly changing world of insurance plans.

Full payment is due at time of service. We are happy to accept cash, your check, Master Card, Visa, American Express or Discover.

We do have pre-payment packages available as well as interest-free financing through a third party company with no credit check, just ask a member of our staff when you come in.


We accept all major PPO insurance plans. However, we are only in-network with BlueCross BlueShield.

Your insurance is an agreement between you, your employer, and your insurance company, not between your insurance company and our office.  We are NOT included in your contract. And NOT all services are covered by all insurance policies.  We cannot be certain if your insurance covers Chiropractic, although most policies do provide coverage.  The amount they pay varies from one policy to another.  The “Usual and Customary Charges” that may be quoted by your insurance company are charges that have been determined and set by your insurance company.  They do not necessarily reflect our fees.  When possible, we will call to verify benefits on your insurance; however, the benefits quoted to us by your insurance company is not a guarantee of payment. As a courtesy to you, our office will bill your insurance for you, electronically, at no additional charge. In order for our office to bill your insurance, you must sign a patient financial responsibility form as well as the insurance claim form. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductibles, co-pays or co-insurance.

Insurance glossary:

  1. Deductible: In order for your insurance to pay for your medical claims, your deductible has to be paid in full by you, the insured.
  2. Co-Pay/Co-Payment:  The amount an insured person is expected and required to pay for a medical expense at the time of the visit.
  3. Co-Insurance:  The insured’s share of covered health insurance benefits, usually a percentage.
  4. The Insured:  You, the patient

We do accept assignment from Medicare.  The check is usually sent directly to our office in payment of the services that Medicare will cover; which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible of $162 has been met.  You are required to pay the deductible and the remaining 20%. All other services we provide are NON-COVERED. These services include, but are not limited to, x-rays, examinations, manipulation of extremities, therapies, acupuncture, orthotics, supports, and/or nutritional supplements.  Medicare patients are fully responsible for charges of non-covered services.  Secondary insurance may or may not pay for these non-covered services and may or may not include a deductible. Our office completes and files the forms for Medicare at no charge. In order for our office to bill Medicare and your secondary insurance plan, you must sign the advanced beneficiary notice of non-coverage (ABN), a form required by Medicare, as well as the insurance claim form.


Please bring with you your photo i.d, your auto insurance card, your health insurance card, accident claim number, police report, and tell us if you have retained an attorney.

“ON THE JOB” INJURY (Worker’s Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance by two health care providers of your choice. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance along with a claim number for your case. In order for our office to bill your work comp insurance plan, you must sign the patient responsibility form and claim form. If your employer does not provide us with this information, if a settlement has not been made within 6 months, or if you suspend or terminate care, any fees and services are due immediately.