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Home
Patient Center
Patient Forms
Contact
Our Staff
Gift Certificates
Purchase Promotions
Memberships and Pricing
Virtual Tour & Patient Stories
Event Registration
Employment
Services
Massage
Chiropractic
Prenatal & Peds Chiropractic
Rehabilitation
Kinesio Taping
Pain Management
Pain Management Services
Laser Pet Therapy
Acupuncture
Auto Accidents
Reflexology/Reiki
Laser Services
Laser Hair Removal
Sun Spot Treatment
Vein Treatments
MonaLisa Touch
TempSure® Vitalia Vaginal Rejuvenation
Skin Renewal
Scalp Massage
MedSpa
Skin Care Treatments
Skin Care Products
MDPen Microneedling
Microcurrent Therapy
Microneedling
Infusion Therapies
Red Light Therapy
Red Light Treatments
Infrared Sauna
Body Sculpting
Body Sculpting Services
FlexSure
TempSure Firm
TempSure Envi
Body Contouring
Infrared Sauna
Lypossage
Nutrition
Personal Training
Stretch Center
Education
IIE Massage Therapist Program
IIE CEU’s
IIE Community Seminars
IIE Class Registration Portal
Body Scan Tool
Insurance Orientation Acknowledgement Form – Rockford, IL
Insurance Orientation Acknowledgement Form
Insurance Orientation Acknowledgement Form – Rockford, IL
Upon completing the insurance orientation, please complete the form below.
Date
First Name
Last Name
Phone
Email
Please rate the following questions with number options, with 10 being completely agree and 0 being completely disagree
I understand that Integrated Family Healthcare, LLC (Dr Colleen Noe), Dr Nellie Christ each set their own fees that are billed to the insurance company. Circle of Wellness handles all business transactions and is legally contracted as the medical management group of those companies.
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I am now better informed about the requirements from my insurance to cover care
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I understand what a Plan of Care is
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I understand the importance of following through with all of the services prescribed in the Plan of Care
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I understand what is expected during treatments
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The information presented was helpful
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Suggestions Regarding the Orientation
Questions / Comments
Insurance Services Orientation Acknowledgement
I have completed the Insurance Services Orientation
I understand the information that was presented or will contact Circle of Wellness staff with questions
By clicking this box and entering my name in the signature field below, I am agreeing to the previous statements
Patient Name (signature)
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