Insurance Verification Form

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Fill out this form completely so we have all of the information necessary to verify your acupuncture insurance benefits. All information is 2-step password protected on our end. We will contact you directly when the verification is complete.

Patient Information:

All information is kept secure through both servers and cloud-based security

First Name *

Last Name *

Sex *

Date of Birth *

YYYY

Phone number *

Email *

Residential Address *

City, State, Zip code *

Primary Diagnosis/Chief Complaint *

Services you are interested in for insurance benefit information *

Acupuncture

Chiropractic Care

Physical Therapy (out of network benefits only)

Employer Name *

Name of Insurance Company *

Provider Services Phone Number (located on the back of your insurance card) *

Policy/ID Number *

Group Number

Relationship to Insured *

If (MVA) Motor Vehicle Accident or (WC) Worker's Compensation please provide your 1. Claim number 2. Adjusters name 3. Adjuster's phone number or email address

Questions and comments

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