New Patients

Please complete the following forms and email to

1. Download each form to your desktop.

2. Complete the form and click SUBMIT at bottom of form and follow directions to email.

3. If unable to SUBMIT direct from form simply email forms as an attachment directly to

New Patient Intake Forms

Insurance Verification Form

**Please complete and email the New Patient Intake Forms and Insurance Verification Form before your first visit to allow more time for treatment.

**Please encrypt your message when emailing your forms to Dr. Ben to ensure your privacy.

Dr. Kleinbrodt is currently a PPO participating provider for Blue Cross, Blue Shield, Aetna, Cigna, United, as well as many other insurance plans. If you have any questions about whether or not chiropractic is covered with your insurance plan, please complete our insurance verification form, or call our office, so we can verify your benefits.

What you should know about overall insurance benefits:
It is important to understand what your benefits are and how you are covered.

  • Co-Pay: The amount your insurance company says you are responsible for paying for every visit. Payment can range from $0 to $90, depending on your plan.
    Please note that ART may not be covered by insurance and may require an additional co-pay.
  • Deductible: The amount of money you must spend out-of-pocket in one year before your insurance begins covering visits. Numbers can range from $0 to $10,000, depending on your plan.
  • Co-Insurance: Some companies have an agreement where they will only pay a percentage of bill and you are responsible for the remaining amount. For example, your insurance carrier may agree to only pay 70% of the bill and you pay the remaining 30%. Again, this number varies depending on your plan.

At Brentwood Spine & Sport, we understand that insurance plans can be confusing, so we verify your insurance benefits and help explain them to you.

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