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Online Forms

We offer our paperwork on line so you can complete it in the convenience of your own home. If you have any questions or concerns, please feel free to call Andover Family Chiropractic at (316) 733-0715.


New Patient Forms

PDF Icon   New Patient Forms  Download & Print Forms. Bring completed forms to the office during your first appointment.


HIPPA Privacy Policy

PDF IconHIPPA Privacy Notice The government requires we post a copy of our Notice of Privacy Policy and Notice of Material Changes to our Privacy Practices Policy.


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 or call (316) 462-5000.

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