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Name of Practice Election Not to File Health Insurance Claims(This form is only for non Patients.) The chiropractor(s) at this practice are participating (in network) providers for your health benefit

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What is this form is only?

This form is only used for reporting purposes.

Who is required to file this form is only?

Anyone who meets the reporting requirements.

How to fill out this form is only?

The form can be filled out online or submitted by mail.

What is the purpose of this form is only?

The purpose of this form is to gather specific information.

What information must be reported on this form is only?

The form requires specific details about the subject matter.