Please print out these forms, complete and bring with you to your appointment. Additional forms may be required on your visit. But these will save you some time.
For the Neck, Back and Extremity Indices, complete only if you have complaints in those regions. We use these forms for your conditions including those related to accident treatment and chiropractic treatments in Altamonte Springs and other Orlando Cities.
Copies are available in our office as well.
Motor Vehicle Accident Only Patient Forms
Dynamic Care, Inc insurance plans accepted: We accept all major health insurance plans. We accept all auto insurance plans. Dr. Loperfito is a provider (in-network) for the following major medical plans:
Health Insurance, Dynamic Care, Inc. Accident Treatment injury/ accident, Private Pay and all other Patients Forms
We also accept:
* Some Cigna plans
* Most Humana
* State Farm
Not all insurance accepted in Altamonte Springs is taken at our office.
We are not accepting all new Medicare patients at this time. Sorry, we are not a Medicaid provider.
Plans such as Blue Cross Blue Shield of Florida, Cigna, United, Humana, Aetna are private health insurance plans that usually cover chiropractic care and similar treatments. We are providers for many Blue Cross Blue Shield insurance plans. Blue Cross has PPOs and HMO type plans. Blue Cross typically doesn not require authorization for its Blue Cross insured. We are in network for some Cigna insurance plans. Cigna has PPO and HMO insurance plans. Some United healthcare plans require authorization for treatment. We are in-network for Humana PPO insurance plans. Humana has PPO and HMO insurance plans. Humana typically does not require authorization for treatment to its insured.
Insurance plans such as State Farm, Nationwide, Geico, Progressive, Travelers, Esurance, USAA, Mercury and others, have medical benefits for treatment related to automobile, car, motor vehicle accidents. This is called PIP or personal injury protection coverage. Please see our page for Accident/ Injury. State Farm, Nationwide, Geico, Progressive, Esurance, USAA, Mercury medical insurance do not require authorization.
We are also providers for some discount plans including:
For print and online advertisements
Standard Ad Disclaimer
The following relates to advertisements that may include free or reduced fee services. Similar to other chiropractors, our office has promotions periodically. Please call for specific details. Many have expiration dates. Some are related to health fair or health screening or similar events we participate.
THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.
* United HealthCare
* Some Blue Cross Blue Shield plans