Intuitive Healing Acupuncture

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Reason for visit

Patient name

Email address

Phone number

Available times

Wed, Oct 21

No availabilities found on this day.

Thu, Oct 22

No availabilities found on this day.

Fri, Oct 23

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Sat, Oct 24

No availabilities found on this day.

Insurance verification

Insurance Information

My practice accepts (most) insurance plans. Please be familiar with your individual medical insurance plan and 1) if Acupuncture is a covered service or 2) if a Referral is required to receive acupuncture services. As a courtesy, your insurance benefits can be verified prior to your appointment. Pleased be advised that verification of benefits is not a guarantee of payment. Ultimately, payments are the responsibility of the patient and you should be familiar with your medical insurance plan details. Office Visit Fees, Co-Pay, and Deductible amounts are due at the time of service. Upon completing online forms, please read and sign the Financial Policy Agreement.

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

Employment Accident? Workers Compensation

Date of injury Please bring your authorization form to the office

Case/Claim #

Employers Name

Employers Address

Insurance company name

Insurance company phone

Insurance company address

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