EM Insurance Verification Form (IVF)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We are currently in-network with Cigna plans only. Please note that having a Cigna health insurance plan does not guarantee that your acupuncture services are covered.

Please allow 3-5 business days for results which you will receive via the email address you provide below.

Are you looking to use auto-insurance med-pay for your treatments? Please fill out this form instead: https://forms.gle/VfigsHAqU69YKWmw7

Worker's Compensation? Use this form: https://forms.gle/RU49uBvXEtKxyq97A

Out-of-network plans: EM is not currently filing claims for any out-of-network plans. You will receive a prompt-pay discount on your treatments (see most current fee schedule at https://bit.ly/3euoIUn) and may request a superbill, which you can use to self-file your claims to your insurance plan.

You can find our full policy on insurance here. Please send any additional questions to: admin@energymatterseastbay.com

Email *

First Name *

Last Name *

Date of Birth *

YYYY

Sex *

Please choose the sex listed on your insurance card, as required by our verification system. Your answer will be used solely to verify your insurance coverage, and will not be disclosed or shared as part of your treatment at Energy Matters.

Phone Number *

Address *

City, State *

Zip *

Insurance Carrier *

Member ID *

Group # *

Insurance Plan Phone *

Can usually be found on the back of the card next to "Providers"

If applicable:

PPO

HMO

POS

EPO

Medicare Supplemental

Clear selection

Name of primary insured *

Date of next appointment

Leave blank if you do not have an appointment scheduled.

YYYY

Notes?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Energymatterseastbay.com. Report Abuse

Forms