Insurance Verification for Acupuncture Benefits
Please allow the office up one business day to verify your coverage. We will notify you via email of your benefits for the practice and covered doctors.
Sign in to Google to save your progress. Learn more
Email *
Please select your Primary Insurance: *
Required
Member ID *
Group Number if Available
Insured Name:                                                                              Please list as shown on insurance card *
Date of Birth: *
MM
/
DD
/
YYYY
Subscriber Relationship to Patient: *
Other Insured Name and Date of Birth:
Do you have a deductible?
Clear selection
Have you already verified your acupuncture benefits?
Is there a secondary insurance?
Clear selection
For Secondary Insurance Only:                                                            Please list the insurance information below including insurance carrier, member id, insured name and date of birth
Please complete below and date:                                                                       I,_____________________________________________ (Patient name if over 18 yrs.) verify that the information stated above is correct and that I will be responsible for any charges that my insurance company, _____________________________, does not cover after treatment has been rendered. This may include any co-payments, out-of-network provider or facility charges over the "allowed amount", or procedures that are not covered under my insurance policy.                   *
I agree to the above stated terms and conditions. A copy can be provided upon request. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms