Official New patient form

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Confidential Insurance verification request

If you would like UHI staff to verify your insurance

in advance of your visit, please fill out the questions below. Typically verifications require two days to finish because we do verifications live!

(Make sure you fill out the questions marked with an asterisk!)

What services are you interested in?

ChiropracticPhysical TherapyMassage TherapyAcupunctureCraniosacral

What time is more convenient for us to call you with your insurance benefits?

Weekday Mornings (M-F 8:30 am-12:00 pm)Weekday Afternoon (M-F 12:00 pm-5:00 pm)Weekday Evening (M-Th 5:00 pm-7:00 pm)Weekend Morning (Sat-Sun 8:30 am-12:00 pm)Weekend Afternoon (Sat-Sun 12:00 pm-3:00 pm)I prefer to have them emailed

I would like to receive future communications

I agree to the GDPR Terms & Conditions

I confirm that I am at least 16 years of age or older

I have read and accept any EULA, Terms and Conditions, Acceptable Use Policy, and/or Data Processing Addendum which has been provided to me in connection with the software, products and/or services.

I have been fully informed and consent to the collection and use of my personal data for any purpose in connection with the software, products and/or services.

I understand that certain data, including personal data, must be collected or processed in order for you to provide any products or services I have requested or contracted for. I understand that in some cases it may be required to use cookies or similar tracking to provide those products or services..

I understand that I have the right to request access annually to any personal data you have obtained or collected regarding me. You have agreed to provide me with a record of my personal data in a readable format.

I also understand that I can revoke my consent and that I have the right to be forgotten. If I revoke my consent you will stop collecting or processing my personal data. I understand that if I revoke my consent, you may be unable to provide contracted products or services to me, and I can not hold you responsible for that.

Likewise, if I properly request to be forgotten, you will delete the data you have for me, or make it inaccessible. I also understand that if there is a dispute regarding my personal data, I can contact someone who is responsible for handling data-related concerns. If we are unable to resolve any issue, you will provide an independent service to arbitrate a resolution. If I have any questions regarding my rights or privacy, I can contact the email address provided.

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