Insurance Verification Form

Insurance Verification Form

We are an out of network provider.  Please note, verification of insurance does not guarantee coverage of acupuncture services. To best serve you, we invite you to verify your insurance coverage by completing the form below before your first scheduled session. Insurance companies are typically open Monday - Friday during regular business hours. Benefits cannot be verified outside of business hours. Please allow 48-72 hours for a response. The time-of-service cash rate will be charged if your insurance benefits are not verified before hand. If one finds they have benefits after their first visit, they will have a credit towards future co-pays.  

 
Name *
Name
Phone *
Phone
Best number to reach you
Insurance Company *
What's the name of your primary health Insurance
You can find this on your card [ this is not the group number}
Date of Birth *
Date of Birth
Insurance Company Phone Number for Providers *
Insurance Company Phone Number for Providers
Often times, the number is located on the back of your card.. Please be sure to list the number that says, "PROVIDER SERVICES"
Please write the name of your insurance company if you selected "Other"