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Complete Fillable PDFs (Below)
A few of the most common forms have been updated effective January 2024. Some are PDF “print ready” downloads and some will soon be fillable PDFs. Please read and select carefully from options below. Some PDF forms (below) are best viewed and/or completed or printed in Safari or Microsoft Edge browsers.
Disclaimers & Releases (Please see below): Soteria Healthcare Network, Inc. provides these forms, web forms, downloads and/or links to you only as a courtesy and convenience. You understand the inclusion of any link does not imply a financial or business relationship or endorsement by Soteria Healthcare Network, Inc. of any company, the web site or its products or services. For security and convenience, Soteria Healthcare Network, Inc. has a Business Associate Agreement (BAA) with JotForm, a HIPAA compliant, online web form partner. You understand that your use of, click on, and/or visit to a third-party web site or web form, download or link is not without risk and you are bound the Terms of Use Privacy Statement and/or Editorial Policy of that Web site and Soteria Healthcare Network’s Terms and Conditions and Privacy Policy. Your use of these web forms indemnifies Soteria Healthcare Network, Inc., it’s agents and/or representatives from any liability or damages now and/or in the future. Soteria Healthcare Network, Inc. is not responsible or liable directly or indirectly for any damages or loss of Personal Health Information (PHI) or Personal Identification Information (PII) caused or alleged to be caused by or in connection with your use of or reliance on any content shared with third parties, their goods or services they make available on or through any such affiliated web site. Jotform’s HIPAA forms encrypt the data you provide on your web form and then transfer and store the data while keeping it encrypted. Please (see below) Disclaimers, Releases, PHI & PII Disclosures, Terms & Conditions of Use Related To Our Web Site & Submission & Collection from Web Forms & Downloads.
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Initial Visit Treatment Plan Form (U.M.)
Instructions: A new “2024 PDF” is available off 01/03/2024! Please download and print this PDF. If answers are not complete and/or accurate, this form may be returned without authorization. This form is required if the Patient’s condition requires care beyond one visit. Please note, please be as detailed/accurate as possible. If not, additional information may be required upon request. Thank you. Any questions/comments, please call 770-455-8190 ext 119 or fax # 404-341-9804
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Follow Up Treatment Plan Form (U.M.)
Instructions: This form is required if the patient’s condition requires care beyond one visit. Additional information may be required upon request. If all answers are not complete and accurate, this form will be returned without authorization.
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Date Extension Request(s)
Instructions: On occasion or if necessary, please complete this new print-ready PDF with the required information and reason(s) for the date extension request. Please fill out, print, sign and return to Soteria.
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Update Your W-9 Tax Form
Due Date: Feb 15 of each year
INSTRUCTIONS: If you’ve moved, open a new location or have not submitted an updated W-9 to Soteria Healthcare in the past 12-mos, please complete this form.
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Annual Provider Information Update Form
Due Date: Feb 15 of each year
INSTRUCTIONS: If you’ve moved, relocated or added a new location) and let’s make your update official. Please be sure to also submit an updated W-9 with this form.
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Primary Payor Form (Required Annually from Patient)
Instructions: Please have the Patient/Member complete this form ON THEIR FIRST VISIT OF THE CALENDAR YEAR OR, IF THE MEMBER/PATIENT EMPLOYER and/or HEALTH INSURANCE HAS CHANGED. Please return to Soteria Healthcare Network at fax 404-341-9804 or mail to the address below. Please note, no edits and/or changes/updates will be made within our system(s) until all of this information is received and verified by one of our representatives and a member of our staff. Once signed and completed, please mail or fax this document along with the “Initial Chiropractic Treatment Plan Form”. Any questions/comments, please call 770-455-8190 ext 119.
Disclaimers, Releases, PHI & PII Disclosures, Terms & Conditions of Use Related To Our Web Site & Submission & Collection from Web Forms & Downloads
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Soteria Healthcare Network, Inc. provides these forms, web forms, downloads and/or links to you only as a courtesy and convenience. You understand the inclusion of any link does not imply a financial or business relationship or endorsement by Soteria Healthcare Network, Inc. of any company, the web site or its products or services. For security and convenience, Soteria Healthcare Network, Inc. has a Business Associate Agreement (BAA) with JotForm, a HIPAA compliant, online web form partner. Once you link and/or visit to a third-party web site you will be subject to the Terms of Use, Privacy Statement and/or Editorial Policy of that Web site. Your use of or linking to such web sites is at your own risk. Soteria Healthcare Network, Inc. is not responsible or liable directly or indirectly for any damages or loss caused or alleged to be caused by or in connection with your use of or reliance on any content goods or services available on or through any such web site. Jotform’s HIPAA forms encrypt the data you provide on your web form and then transfer and store the data while keeping it encrypted. The form data is stored in JotForms encrypted databases and on JotForm servers that enable HIPAA compliance. JotForm web forms, information submitted through these web forms, downloads or third-party links, references, sources, mentions and/or referenced web sites are not under the control of Soteria Healthcare Network, Inc., and Soteria Healthcare Network, Inc., its agents, representatives, employees, etc.,. are not responsible for the maintenance or security of content submitted on these forms, nor of any linked web site or any link contained in a linked web site or any changes or updates to such web sites. Soteria Healthcare Network, Inc. is not responsible for any activities, breach, loss, damages, breach of PHI or HIPAA violation that you may incur, engage in or on or from any linked web site including without limitation the use of online web forms, the purchase of products, downloads found on Soteria web properties or web site(s) or services. Have a question about how Soteria Healthcare Network uses Jotform to help you manage your HIPAA data on our web forms? Check out JotForm’s FAQs. These servers are separated from the internet using multiple levels of protection and firewalls. Your use of these forms, downloads, etc., constitutes your agreement and acceptance of release of Soteria Healthcare Network, Inc., it’s agents and affiliated representatives and published/posted Soteria Healthcare Network, Inc. Terms and Conditions and Privacy Policy Statements.
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HOW DOES SOTERIA HEALTHCARE NETWORK, INC. USE PERSONAL INFORMATION (PII) AND PERSONAL HEALTHCARE INFORMATION (PHI)?
Using any online web site, contact form, web form, web property, etc., is not without risk. We ask you do not submit personally identifiable information (PII) nor personal health information (PHI) through unsecure web site(s), contact form, web forms, etc. Your use of this web site constitutes your consent and release of Soteria Healthcare Network, Inc. from any damages or breach of PII and/or PHI you provided, sent, emailed, faxed, submitted, etc., through a Soteria Healthcare Network contact form found on our web site, a third party BAA web form, fillable web forms, downloads provided here and/or submitted, the the like. You further understand and release Soteria Healthcare Network, Inc., its agents, contracted third party BAA vendors, clients, representatives, etc., from all liability and/or damages. Soteria Healthcare Network, Inc., collects personal information (including, but not limited to name, e-mail address, tax id, NPI, mailing address, and/or telephone number) when user(s) commences communications with us. If you provide your e-mail address, postal address, and/or telephone number to us, we will collect and store such information and may use it to communicate with you. Additionally, when any personal or general information is sent through Soteria Healthcare Network, Inc. web site, third party web forms under our BAA, any information will be directed to appropriate Soteria Healthcare Network, Inc. staff from the person(s) responsible for supporting the managing such issues. Such information may be given to the person(s) appropriately suited to process the request, resolve the issue, answer specific questions, or resolve concerns. User(s) may also be contacted via phone, fax, U.S. Mail, courier and/or e-mail if Soteria Healthcare Network, Inc. needs to clarify information submitted or if Soteria Healthcare Network, Inc. agents/representatives feel the requested information is best conveyed via phone, fax, U.S. Mail or email. See latest disclosures, disclaimers, releases and Terms and Conditions and Privacy Policy from Soteria Healthcare Network for more information.
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Read latest terms and conditions
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Read latest terms and conditions