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.

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* 1. Patient Information

First Name

Last Name

Date of Birth

Address

City, State

Zip Code

Email Address

Phone Number

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* 2. What is your primary reason for coming in for treatment?

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* 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

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* 4. Relationship to the insured:

Self

Spouse

Parent

Legal Guardian

Other

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* 5. Insurance Information

Provider

Name of Insured

Provider Phone Number (on back of your insurance card)

DOB of Insured (if not 'Self')

Member ID#

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* 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.