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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.

Disclosure of Ownership and Management Information Required

In accordance with regulatory requirements of the Minnesota Department of Human Services (DHS) and the Centers for Medicare & Medicaid Services (CMS) regulations, all payors, including Fulcrum must collect and maintain information regarding disclosure of ownership and management information from all providers in its network on an annual basis.

It is important the entire form is completed before submitting to Fulcrum – even if this means indicating an “N/A” for items that do not apply to your business. A signature is also required. Forms that are received incomplete or not signed will not be accepted.

The Disclosure of Ownership and Management Information & Exclusions Statement form is a regulatory requirement for all organizations serving Medicaid (MHCP) patients, so you may have already completed this form for other insurance carriers. If you already have a form previously submitted to another payor, you may submit that same form directly to Fulcrum.

The Disclosure of Ownership and Management Information & Exclusions Statement form (below) can be filled out and submitted electronically. (If the form isn’t writable, please download it and open using Adobe Reader.) After the form is completed, simply click the “Submit Form” button in the upper right corner of the document and follow the instructions to email it to Fulcrum. If the electronic submission feature isn’t working, feel free to fax the form to us at (651) 389-2009.

If you have any questions or need assistance with this form, please contact Fulcrum at (651) 389-2006 or (866) 714-0524.

Disclosure of Ownership and Management Information & Exclusions Statement for Providers | PDF

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.

Commercial and Medicaid-Financial Disclosure Form | PDF

Policy Overview | PDF

Medicare Member Consent for Non-Covered Service Form | PDF

FAQ: Medicare Patient Billing Policy Change | PDF

 

*For additional information or assistance regarding these documents, please contact our Provider Services Department by calling (888) 638-7719.

Credentialing Forms and Contracts For Applying to the ChiroCare Network

To begin the credentialing process, please review our stringent qualifications and practice requirements in the ChiroCare Complete Credentialing Guidelines document below.If you meet our requirements, please contact our Application Request Line at (888) 638-7719 ext. 41112.

To obtain information on Fulcrum’s ChiroCare provider reimbursement rates, you may call our Provider Services Department at 1-888-638-7719.

 

Listing Fulcrum on Your Certificate of Insurance

Fulcrum requires ChiroCare network providers to list ChiroCare on their Certificate of Insurance. For new providers, this requirement must be met when joining the ChiroCare network while previously contracted providers are required to do this during re-credentialing. To help you complete this step in the credentialing or re-credentialing process, we have designed the following forms.

Request to Add Certificate Holder Form | PDF

Please complete the form and fax it to your malpractice insurance holder.

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.

Questions specific to the TRIIUM program may be directed to Sharon Puttonen at 1-952-883-3139 or sputtonen@triium.com.

Already a TRIIUM Member?

Contact Sharon Puttonen at 1-952-883-3139 or sputtonen@triium.com 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

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.

ChiroCare network providers who wish to participate in this program must sign the Participating Provider Agreement Addendum (listed below) and fax or mail the signature page to Fulcrum at:

Fulcrum
Attn: Workers’ Compensation Program
1000 County Road E, Suite 230
Shoreview, MN 55126
Fax 1-651-389-2009

When submitting the signature page, please make sure the contracted ChiroCare network provider’s name is legible in the “Name” field. ChiroCare network providers who do not return an executed Addendum signature page will be considered non-par and will not be eligible for workers’ compensation referrals.

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 1-888-638-7719.