Insurance Verification - Unveiling Wellness
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Contact Preference *
Patient Information
First Name *
Middle Initial
Last Name *
Social Security Number *
Date of Birth *
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DD
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Sex *
Patient Phone Number *
Patient Email Address *
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Chief Complaint / Primary Diagnosis *
Insurance Information
Employer's Name *
Insurance Company Name *
Insurance Phone Number *
Policy Number/ ID Number (including 3-letter prefix for BCBS) *
Relationship to Insured *
Group Number *
Claim # if an Accident
Date of Accident/ Injury
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DD
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YYYY
Date of Accident/ Injury
MM
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DD
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YYYY
Additional Notes
Notes or Comments
Insurance and Billing Policy


● At time of service fee (price listed on our service menu) is due upon receiving the service

● We submit claims on your behalf for each one of your appointments to our billing company to send to your insurance. We do this immediately in an attempt to activate your coverage as soon as possible.

● In the event you have an out of network deductible to meet, we will keep submitting claims until your deductible is met and we will update you as soon as we receive notification that’s happened.

● Even if your policy has no out of network deductible to meet, we need to see reimbursement payment posted in order to know what an appropriate co-pay is for you. Co-pays can range from $10 to $65, depending on the details of your policy’s coverage for acupuncture.

● If you accrue credit with us (this can happen if your insurance reimburses us for one or more of the services you have paid full menu price for) this will be credited back to you in the form of complimentary services from us until you no longer have a credit balance, at which point you will owe only your copay for the remaining appointments your policy covers through the remainder of your policy’s term.

● We cannot give cash refunds for payments made on services that are later reimbursed by insurance and we cannot waive co-pays, as this is illegal and violates the terms of insurance billing.

I have read and agree to the Insurance and Billing Policies stated above. *
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