Acupuncture Insurance Verification Please answer the following questions so that we may determine your insurance coverage. Please allow 2-3 days to process your verification. Question Title * 1. Patient Information First Name Last Name Date of Birth Address City, State Zip Code Email Address Phone Number Question Title * 2. What is your primary reason for coming in for treatment? Question Title * 3. Please indicate if you experience any of the following (check all that apply): Neck Pain Upper Back Pain Lower Back Pain Tension Headache Migraine Nausea Question Title * 4. Relationship to the insured: Self Spouse Parent Legal Guardian Other Question Title * 5. Insurance Information Provider Name of Insured Provider Phone Number (on back of your insurance card) DOB of Insured (if not 'Self') Member ID# Question Title * 6. Please type your name in the space below to confirm your agreement with the following: I understand that I am financially responsible for all acupuncture treatments- including my initial appointment- that are not covered by my health insurance policy. I also understand that if I need to cancel my appointment for any reason, I must do so within 24 hours of my scheduled appointment to avoid late cancellation fees. Submit