FORMS 

We offer our paperwork online so you can complete it in the convenience of your own home. Please fill them out to the best of your ability and bring the appropriate forms to your appointment.

Please verify your insurance benefits with your insurance company if you have any questions.

INTAKE FORMS 

All patients being seen by Dr. Amy will need to fill out all of the intake paperwork, especially the Intake, Consent to Treat, and Consent to Use PHI forms.

INTAKE FORM

Please fill this out to the best of your ability. Your condition and information will be reviewed in detailed at your appointment during your exam. 

PATIENT FINANCIAL FORM

The first page of this form includes information on your medical insurance and who is responsible for payment on your account. There is an optional credit card consent form that you are able to fill out if you would like to keep your card on file at our office or would like your statements emailed versus mailed. 

**As a note, we are PARTICIPATING with BCBS, Sanford, United Healthcare, Medica, and the Optum Health umbrella.
**We are NON-PARTICIPATING with Medicare. Medicare requires by law, as does the standard of care we hold our office to, that we perform a new patient exam. Medicare does NOT cover this fee. If you are a Medicare patient, you will be required to pay our new patient exam fee at the time of service.
**We are also NON-PARTICIPATING with Aetna and Healthpartners
**If you have questions about your insurance network, please contact your insurer directly by contacting the number on the back of your insurance card. 

CONSENT TO TREAT FORM

This form gives us permission to examine and treat you. It also discusses our general office policies and our financial policy. 

CONSENT TO USE PHI FORM

This form gives us consent to use your protected health information (PHI) for the purposes of treatment, obtaining payment, or supporting the day-to-day healthcare operations of our office. Please also download the Patient Privacy Notice policy for our full policy. 

PATIENT PRIVACY NOTICE

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.  Please review it carefully.

OUTCOME ASSESSMENT TOOLS 

Fill out the form that is most applicable to your type/region of pain.

UPPER EXTREMITY FUNCTIONAL INDEX

This questionnaire is designed to enable us to understand how much your Upper Extremity pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just select the one choice which most closely describes your problem right now.

LOWER EXTREMITY FUNCTIONAL SCALE

This questionnaire is designed to enable us to understand how much your Lower Extremity pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just select the one choice which most closely describes your problem right now.

LOW BACK - OSWESTRY

This questionnaire is designed to enable us to understand how much your Low Back pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just select the one choice which most closely describes your problem right now.

NECK PAIN

This questionnaire is designed to enable us to understand how much your Neck pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just select the one choice which most closely describes your problem right now.

Move Chiropractic

Address:
4500 36th Ave S STE 100
Fargo, ND 58104

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