On-Site Emergency Medical Condition Determination Request

On-Site Emergency Medical Condition Determination Request

$0.00

Our team will go to your office and examine each patient an EMC determination request has been made for. Afterward, we bill each patients insurance company for our service using CPT code 99204. There is no out-of-pocket expense for the referring chiropractor.

Once you fill out and submit the form located below, we will review your submission. A member of our staff will then contact you with more information and to schedule our visit.

This service applies for the entire state of Florida. Minimum 3 patients to qualify for this service IF you are located north of Orlando. Please understand that there are no guarantees of an EMC diagnosis.

Quantity:

Please see below

Doctor/Contact Person

First Name

Last Name

Contact Number

(###)

###

####

Office Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Name(s)

Message

Once your form is submitted, we will review your information and contact you with additional details.