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Acupuncture Insurance Verification Form

Please complete the form below and we will verify acupuncture insurance coverage and benefits (if any). Any required field that does not apply to you for please put ‘n/a’. This process can take a few days. Please be patient. If you do not hear back from us within five days (not including weekends). Please give us a call.

Patient Name:*
Patient Email:*
Patient Contact Number:*
Patient DOB (mm/dd/yyyy):*
Patient's Reason for Treatment:*
Primary Insurance Card Holder's Name:*
Primary Card Holder's DOB (mm/dd/yyyy):*
Insurance Company:*
Insurance ID#:*
Insurance Group#:*
Insurance Type of Plan (HMO/PPO/POS/Others):*
Insurance Company Phone Number:*
Attach scan/photo of the front and back of your insurance card if possible (2Mb maximum) (you can use your mobile phone to take the photo).
* fields are required