Get the free This clinic is owned and operated by Gallo Chiropractic, PC
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In. lbs. 1. Have you had chiropractic care before c Yes c No Occupation For how long yrs. F mos. If yes how recently 2. FORM CMS-R-131 EXP. 03/2020 FORM APPROVED OMB NO. 0938-0566 PATIENT INFORMATION Patient ID Keytag Number First Name Last Name Gender c M c F Date of Birth / Age Home Address City State Phone c W c H c C Zip Code 2nd Phone Email What is your preferred method of communication c Phone c Text c Email Employer Work Address Emergency Contact Are you Medicare Eligible c Yes c No Do...
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What is this clinic is owned?
This clinic is owned refers to ownership information for a clinic.
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The clinic is owned form must be completed with accurate ownership details.
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The purpose is to provide transparency about clinic ownership.
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Ownership details such as names, addresses, and ownership percentages must be reported.
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