Dr. Jennifer Ashby, DAOM

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Reason for visit

Patient name

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Available times

Tue, Apr 23

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Wed, Apr 24

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Thu, Apr 25

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Fri, Apr 26

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Sat, Apr 27

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Insurance verification

Insurance Information

Dr. Jennifer Ashby, DAOM takes most insurances that include acupuncture coverage but not all. It is the patients responsibility to verify, for themselves, that she is an In-Network provider, or an Out-of-Network provider, and that the services are covered by your insurance. It is not the clinic's responsibility to insure insurance coverage for the patient.

If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage

Name of Primary Insurance (Blue Cross, Aetna, Anthem etc.)

Insurance Type (HMO, PPO etc.)

ID # on insurance card The ID number on your insurance card

Group number

Insurance Provider Phone Number Located on back of insurance card

Claim address Located on the back of insurance card

City

ZipCode

State

Covered under someone else's insurance plan? Select "yes" if you are covered under someone else's insurance

Patient relationship to insured

First Name of Insured Party First Name of the primary policy holder

Middle Name of Insured Party Middle Name of the primary policy holder

Last Name of Insured Party Last Name of the primary policy holder

Insured Party Date of Birth Date of birth of the primary policy holder

Auto Accident? No-Fault / Personal Injury

Date of accident Please bring your authorization form to the office

Case/Claim #

Case Manager's Name

Case Manager's Phone #

Address to submit claims

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