Chiropractic Benefit Services

4479 Philbrook Sq.
San Diego, CA 92130
800‑883‑0412

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Part 1: Contact information

Name:
Phone:
Secondary phone:
Fax:
Email:
Address:
City - State - Zip:

I do not currently receive The Chiropractic Journal but would like to receive a FREE subscription sent to the above address.

Part 2: General background information

Month/year you started practicing chiropractic:

School graduated from:

Part 3: Current Insurance Information

Current Malpractice Carrier:
Renewal Date:	/ / (mm/dd/yyyy)
Type of Policy (select one):	Claims-Made Occurrence No Insurance
Policy Limits:
Current Premium:
Retroactive Date (if claims-made policy):	/ / (mm/dd/yyyy)

Part 4: Claims history

Have you had either a malpractice claim or a professional board dispute filed against you? Yes No

Part 5: Practice information

State you practice in:

County you practice in:

Are you Full Time or Part Time (20 hours or less office time)?

Are there any MD's in your office? Check if yes.

Which adjuncts do you utilize in your office? Check all that apply.

Adjustments	Massage	Nutrition	Traction
Heat	Ice	Electric Muscle Stimulation	Ultrasound
Diathermy	Acupuncture	Adjustment of Extremities	Homeopathy
Hair Analysis	Breast Exams	Vitamin Injections	Obstetrics
Iridology	Interpretation of diagnostic blood, urine studies	Urinalysis	Surrogate Testing
MRI/CT	EKG Colon	Colon Irrigation	Cold Laser
Other

Do you diagnose or treat medical symptoms such as heart disease, cancer, diabetes, epilepsy, multiple sclerosis, etc.? Yes No

Do you have continuing education credits for the most recent calendar year?
Yes No

Do you belong to any professional chiropractic organizations? Yes No

If yes, which one(s)?

Who is your practice management coach?

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