Download New Patient Forms
(click on bold, red type below to download forms)
New Patient Motor Vehicle Injury form and the Worker's Compensation form are for patients that have been injured as a result of a motor vehicle accident or work injury. These packets include an additional form regarding the details of the accident. This extra form allows the doctors to have greater insight to the injuries experienced. Please select the proper forms for your type of injury.
New Patient Motor Vehicle Injury Form
New Patients
Personal Insurance
At Pure Life Clinic we accept most insurance plans which cover chiropractic, massage or acupuncture. We are able to verify your benefits for each of these services prior to your appointment. Please provide your insurance information, complete name, and date of birth when scheduling for verification.
Motor Vehicle Accident
If you have been in a recent car accident, no matter how minor, you should be seen for a complete evaluation. Injuries can occur at speeds of 6 miles per hour. Under Oregon PIP laws you are entitled to a minimum of $15,000 and up to 3 years of treatment including: chiropractic, massage, acupuncture and physical therapy. There are just a few simple steps to opening a medical claim so you may receive the treatment needed.
Call your insurance company. You will be assigned a “claims adjuster” for your case. That person will help you open your medical claim.
We will need the following information to be able to bill your PIP insurance:
1) Your Car Insurance Company Name
2) Name of Claims Adjustor and Phone number
3) Medical Claim # (get this from your adjustor)
If you need an attorney, or if you just want a free consultation with a lawyer, we have a network of personal injury attorneys that we can refer you to for legal advice.
Work Injury
If you have opened a worker’s compensation claim as result of a recent injury on the job, please contact us to set up an appointment. Under Oregon law, you can receive 18 chiropractic visits or 60 days of care if you see your chiropractor as your “attending physician” first after an injury.
If you are already seeking care from another doctor (your “attending physician”), you can get a referral from that doctor for chiropractic, or change your attending physician to your chiropractor. Patients can change their attending physician up to two times after the initial choice.
Cash
We accept all major credit cards, cash and check at time of service. We have a discounted cash price for payment at time of service.
