Eric E. Gofnung Chiropractic Corp
To request an appointment with us, please provide your contact information by filling out the form below & Select one of these 3 tabs and fill up the contact form [ Ex: Are you Patient …. / Are you Attorney …. / Are you Doctor …. ]
Do You Have an Attorney? YesNo
Date of Accident Have You Received Treatment Before? YesNo Authorization for Treatment Demographic/insurance and Claim information PTP 4600 Letter Claim Forms
Date of Accident
Demographic/insurance and Claim information PTP 4600 Letter Claim Forms Is your client being treated somewhere else? YesNo
Please submit client medical record
Is the patient being represented by an attorney YesNo
Date of Accident Authorization for Treatment Demographic/insurance and Claim information PTP 4600 Letter Claim Forms