New Patient Paperwork

Help the professionals at The Chiropractic Element understand your medical history, type of pain, and injuries by filling out our forms. It will help us develop chiropractic and pain management treatments that will suit your needs. Contact us at (785) 505-1005 today for more details, or to request an appointment.

  • All forms are PDF files. You will need AdobeReader® to view them.
  • If you do not already have AdobeReader® installed on your computer,
    Click Here to download.
  • Download the necessary form(s), print them out and fill in the required information.
  • Bring the necessary form(s) to your appointment.

Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

OFFICE HOURS

Monday
8:00am - 4:00pm

Tuesday
2:00pm - 6:00pm

Wednesday
8:00am - 4:00pm

Thursday
7:00am - 11:00am

Friday
8:00am - 4:00pm

Saturday & Sunday
Closed

Closed M/W/F from 12:00pm - 1:00pm for lunch

The Chiropractic Element

3109 W 6th St STE B
Lawrence, KS 66049

(785) 505-1005