Insurance Verification

Insurance Eligibility Verification

Please submit following information to determine your benefits and whether you qualify for courtesy billing.
Verification of your insurance plan is a courtesy, and can not be guaranteed. We urge you to be proactive with your insurance plan and call the number on the back of the card to see what is covered under your plan. Usually, that information may be obtained by you in a much faster and convenient way.
Verification of insurance does not guarantee coverage of acupuncture benefits.
Unless insurance is verified ahead of time, the time-of-service cash rate will be charged. If one finds they have benefits after their first visit, they will have a credit towards future copays.
Please submit all insurance information in the Insurance Verification Form, we will get back to you within 2 -3 business days.

* Indicates required field

Patient Name *

First

Last

DOB *

Gender *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Subscriber's Name *

First

Last

Relationship to Patient *

Subscriber's DOB *

Name of Insurance Company *

Member/Subscriber ID# *

Group ID # *

Insurance Phone # *

Plan Type *

Plan Effective Date *

Your Contact Phone # *

Your Contact Email *

Let us know if you have any other questions (optional) *

Submit