"Report. Respond. Reform."
An official tool of the Chiropractic Future Reimbursement Workgroup

Purpose:
This national reporting form is built to expose and challenge discriminatory, obstructive, unlawful, or monopolistic insurance reimbursement practices that hinder patient access to chiropractic care. We are identifying patterns, quantifying impact, and building a strategic foundation for reform.

This is not just a complaint form - it is a data-driven effort to empower our profession with real-world evidence and to arm our advocates with what they need to drive systemic change.

Why Your Report Matters:
Your submission is part of a national dataset hosted on the Chiropractic Future website. Each unique issue should be submitted separately so we can accurately track frequency, flag systemic problems, and build cases across states.

Details matter. Precise, state-specific entries allow us to identify trends and, when appropriate, provide information to state associations for follow-up. All within strict compliance with antitrust laws.

Confidentiality:
Your information remains confidential. Since primary purpose is data aggregation, we will only contact you if clarification is needed and you grant permission below.

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1. Email address (Required.)

State and Insurance Plan Information

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2. State of practice (Required.)

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3. Insurance Company or Plan Name (if known)

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4. Plan Type (Required.)

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5. Contract Status (if applicable): (Required.)

Reimbursement Issue Category

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6. Select the primary issue you are reporting (Required.)

Problem Description

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7. Please describe the issue clearly and include any relevant timeline, payer communication, and outcomes. (Required.)

Who is Affected?

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8. Primary Impact (Required.)

Legal or Ethical Nature (Optional)

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9. Which of the following apply? (Select all that apply)

Available Documentation

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10. Do you have supporting materials? (Required.)

Impact Statement

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11. How has this issue impacted patient access or practice operations? (Required.)

Proposed Solutions or Resolution Attempts

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12. Have you taken any action? What do you think would help? (Required.)

Permissions and Follow-Up

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13. May we contact you for clarification, additional information, or to keep you updated on our efforts? (Required.)

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14. May we use your story anonymously for advocacy or public reporting? (Required.)

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15. Would you like to assist in future advocacy or workgroups? (Required.)

Reporter Information (Optional but helpful – kept confidential)

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16. Full name

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17. Practice name

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18. Are you a member of your state association?

Additional Notes

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19. Is there anything else you’d like to share?

🔒 Data Usage Notice
Your submission is secure and confidential. Only the Chiropractic Future Reimbursement Workgroup will review submissions. Data may be aggregated for advocacy, reform proposals, and outreach efforts.

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