Forms for ChiroCare Providers
As a ChiroCare provider, there are a number of chiropractic forms you may need. They are listed below by category. Simply download them, fill them out, and submit them as instructed on the document.
Financial Disclosure Form For Non-Covered Patient Services
The following Financial Disclosure Form and Policy Overview document are designed to help ensure that providers are able to collect all appropriate funds from the patient. Please note that in order to be able to collect any funds for non-covered services from members administered by Fulcrum, a Financial Disclosure Form must be executed by the patient.
Medicaid Financial Disclosure Form | PDF
Medicare Advantage Financial Disclosure Form | PDF
Commercial Financial Disclosure Form | PDF
Policy Overview | PDF
*For additional information or assistance regarding these documents, please contact our Provider Services Department by calling 877-886-4941.
Discounts on Products and Services
Fulcrum’s Discount Purchasing Program (DPP) uses collective bargaining to offer its network providers discounts on a wide variety of products and services, many of which are already available in your office. To take advantage of this cost savings opportunity, view the documents listed below and complete the TRIIUM Enrollment Form.
- Office Depot Welcome Guide | PDF
- TRIIUM Group Purchasing Overview | PDF
- TRIIUM Enrollment Form | PDF
- TRIIUM Vendor List | PDF
Questions specific to the TRIIUM program may be directed to Sharon Puttonen at 1-952-883-3139 or email@example.com.
Already a TRIIUM Member?
Contact Sharon Puttonen at 1-952-883-3139 or firstname.lastname@example.org to get registered with www.Business.OfficeDepot.com, the new online shopping and ordering site for TRIIUM’s members. Sharon can also help you order store purchasing cards for use in any Office Depot or OfficeMax store.
Workers’ Compensation for
HealthPartners offers a wide range of insurance products to its members including medical, dental, and workers’ compensation. Fulcrum and HealthPartners have expanded their agreement to include Fulcrum’s ChiroCare chiropractic network for the delivery of HealthPartners Workers’ Compensation program.
Direct Deposit/EFT Enrollment
Fulcrum has adopted an electronic payment program for all payments to providers. Providers must submit a completed Direct Deposit/EFT Authorization Form prior to the effective date of their network participation.
Direct Deposit/EFT Authorization Form and Instructions | PDF
If you have received an electronic Remittance Advice (RA) but not the corresponding EFT payment, please contact our Accounting Department at 1-866-714-0524. To inquire about a missing or late electronic Remittance Advice (RA), please contact our Provider Services department at 1-877-886-4941.