Pediatric 0-6 New Patient Form

Katherine E. Bruce, DC                                                                                                                                              422 N Columbus St. Lancaster (740) 422-8484

Best phone # to reach you during business hours:
Do you seek help for:

HIPPA Practice’s Requirements

This Practice:

  1. a) Is required by federal law to maintain the privacy of your PHI and to provide you with Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI

  2. b) Under the Privacy Rule, may be required by State Law to grant greater access or maintain greater restrictions on the use of release of your PHI that which is provided for under federal law

  3. c) Is required to abide by the terms of the Privacy Notice

  4. d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains

  5. e) Will distribute any revised Privacy Notice to you prior to implementation

  6. f) Will not retaliate against you for filing a complaint

Effective Date: 04/14/2003
Patient Acknowledgment: By subscribing my name below, I acknowledge receipt of my copy of this Notice, and my understanding and agreement to its terms

Billing Assignment

Injury/Accident Information

Is your condition due to an accident?
Type of Accident:
Have you made a report of your accident:

Insurance Information:


Who is responsible for this account?


Who is responsible for this account?

Assignment and Release:

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above listed insurance company/companies. Iassign directly to The Chiropractic Group all insurance benefits, if any, otherwise payable to me for services rendered. I understand that Iam financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all informationnecessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

By signing below, I acknowledge that The Chiropractic Group has informed me that payment for services and supplies may be deniedunder my health insurance plan, if applicable. I agree that if denied as medically not necessary, not authorized/no referral on file, exceedbenefit limits or any other reason, including non-insured, I accept full responsibility to pay The Chiropractic Group for services or suppliesreceived.

Please circle if your child has or has ever experienced any of the following:


Did your child follow his/her milestones? (Check if achieved)

Thank you for taking the time to fill out this form.

Our Locations

Find us on the map

Office Hours

Our Regular Schedule

Lancaster (Historic Downtown)


8:00 am-5:00 pm


7:00 am-4:00 pm


8:00 am-5:00 pm


7:00 am-4:00 pm


6:00 am-1:00 pm