Odom Chiropractic Clinic

Insurance Benefit Form

Your Phone* Referred By
Chief Complaint*
First Name* Last Name*
DOB Month* Day* Year*

Policy Holder*
Relationship to Patient*
D.O.B. Month* Day* Year*
Primary Insurance Co.*
Customer Service Phone*
Insured's Policy I.D.*
Group*

Requested Appointment Date Month* Day* Year*
Requested Appointment Time*

How did you hear about Dr. Odom?
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Have you been to a chiropractor in the past?* If Yes, how long ago?

*these fields are required

Please call and confirm we received your information - 817-738-9777

Insurance & Payment Plans

Dr. Odom is a preferred provider on many networks and insurance plans. Since plans and coverage changes frequently, call or e-mail us info@odomclinic.com for information on coverage under your specific plan.

Blue Cross / Blue Shield PPO
Cigna HMO
First Health Network
Galaxy Health Network
Great-West Healthcare
Group & Pension Administrators
HealthSmart
Humana Choice Care
Interplan Health Group
Medicare
North Texas Health Network
Private Health Care Systems (PHCS)
Principal Life
Progressive Health
Railroad Medicare
Texas True Choice
United PPO/POS/EPO
Aetna NAP PPO - Contract out of Network

We gladly accept most health insurance. Individuals in need of our services who lack insurance and who are worried about the high costs charged by many other clinics need not worry. We have highly affordable rates and flexible payment plans allowing access to high-quality care for you and your family. For your convenience, we accept Master Card, VISA and Discover.