{"content":[{"text":"Verify your own \n insurance and receive \n an extra $10 off of your \n first visit!","bbox":{"left":0.512827,"top":0.047951,"width":0.33597599999999994,"height":0.12191199999999999}},{"text":"INSURANCE VERIFICATION \n On the front or the back of your insurance card there should be a member services \n telephone number or customer service number. After dialing that number proceed with \n getting the following information:","bbox":{"left":0.157294,"top":0.212601,"width":0.685527,"height":0.08810799999999994}},{"text":"Patient Name:________________________________ \n SSN:______________________________ Birth date:________ \n Card Holder:________________________ Birth date:________ \n Relationship to Insured:________________","bbox":{"left":0.147098,"top":0.336722,"width":0.6733390000000001,"height":0.09642800000000001}},{"text":"Primary Insurance:_____________________ \n Claim address:_________________________________________ \n ID#:____________________ Group #:______________________ \n Provider Services Phone#:____________________ \n Effective Date: ____________","bbox":{"left":0.147098,"top":0.452783,"width":0.6964250000000001,"height":0.119786}},{"text":"Deductible: Y/N Amount $_______________________________ \n Has Deductible been met Y/N Amount met:_________________ \n Out Pocket:_____________________ \n Out of Pocket Met: Y/N Amount met:____________________ \n Co-Insurance %:_____________ Co-Pay: $__________________ \n Any Pre-exisiting Y/N____________________________________ \n Maximum Visits per Year:__________________ \n Maximum $ per year:______________________","bbox":{"left":0.147098,"top":0.617202,"width":0.70997,"height":0.1894959999999999}},{"text":"Is Axis Chiropractic an In-Network Provider for this Plan?","bbox":{"left":0.147098,"top":0.826331,"width":0.613925,"height":0.02688199999999996}},{"text":"Y/N","bbox":{"left":0.787258,"top":0.826331,"width":0.04490700000000003,"height":0.02688199999999996}},{"text":"DISCLAIMER: The patient and other person responsible for payments has a right to refuse to \n pay, cancel payment or be reimbursed for any other service, examination, or treatment, which is \n preformed as a result of and within 72 hours of responding to the advertisement for the free, \n discounted fee or reduced fee services, examination or treatment.","bbox":{"left":0.151216,"top":0.893751,"width":0.696782,"height":0.06078500000000009}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}