Stellhorn Chiropractic

4401 Blum Drive

Fort Wayne, IN 46835

As of October 1, 2015 changes were made behind the scenes at your healthcare provider’s

office. The changes involve something called ICD-10 coding. These codes are a system for

categorizing medical conditions in the healthcare system. ICD stands for International Statistical

Classification of Diseases and Related Health Problems are the core tool used to track

healthcare. The number of difference codes has increased from 13,000 to nearly 70,000 - an

overwhelming amount. The implementation of these new codes is to assist the healthcare

providers who file insurance payment claims electronically. Stellhorn Chiropractic does not

provide diagnostic codes on our receipts.

Stellhorn Chiropractic does not bill insurance companies for direct payment to us nor do we file

insurance claims for patient reimbursement. We will continue to keep our fees at an affordable

level for our patients – which are at or below what a co-pay fee would be at an office where

higher “insurance fees” are charged. We will provide a receipt with chiropractic wellness

codes for patients who wish submit their own claims. However, with the new procedures going

into effect, there is no guarantee insurance companies will allow patients to file on their own.

Claims may also be denied.

These new regulations required us to ensure our patients clearly understand our policy

regarding insurance. After reading this form, please sign and date at the bottom of the page

affirming your understanding. If you need further clarification, please feel free to ask. This form

must be signed and dated by all patients and kept on file.

• This office does not submit claims electronically for insurance reimbursement.

• We are a non-Medicare provider and do not file or provide a statement for Medicare claims.

• This office does not accept Medicaid patients.

• Claims submitted by patients may or may not be reimbursed to you by your insurance company.

• Claims will not be filed by this office on behalf of any patient.

• We will no longer be able to prepare statements at the end of the year with insurance codes.

• It is the responsibility of the patient to maintain all of their own insurance receipts.

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       Patient Signature                                                                  Patient Printed Name                                            

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