Health Healing Hands Acupuncture LLC

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Reason for visit

Patient name

Email address

Phone number

Available times

Sat, May 18

No availabilities found on this day.

Sun, May 19

No availabilities found on this day.

Mon, May 20

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Tue, May 21

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Wed, May 22

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Thu, May 23

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Fri, May 24

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Sat, May 25

No availabilities found on this day.

Insurance verification

Insurance Information

ASSIGNMENT OF BENEFITS / RELEASE OF MEDICAL INFORMATION MUST BE SIGNED FOR INSURANCE CLAIMS. We are in-network with Cigna, BlueCross BlueShield, United Health Care, Optum (Veterans Affairs), and Aetna. We accept patients with out-network with acupuncture benefits. Also, accepts FSA and HSA. Patient Responsibility Depending on Your Insurance: **********Insurance is not a guarantee of payment, therefore the patient is responsible for claims not paid by their insurance company. The patient will be billed for co-insurance after the claims have been processed. Co-payment is due on the day of your visit.******** Credit card information is needed to book an appointment due to our 24-hours cancelation/rescheduling policy. You may be charged for late cancelation/rescheduling or no-shows. Making an appointment is confirming that you understand and agree to our 24-hours cancelation/rescheduling policy and giving us the permission to charge your credit card on file regardless of your signature. Emergency absences will be considered on an individual basis by HHH Acupuncture Clinic. By continuing you are agreeing to the statements above.

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

Cancellation/Rescheduling Policy

Entering a payment method is required to complete the booking of your appointment. If you cancel your appointment within 24 hours of its scheduled start time, your credit card will be charged a late cancellation fee of $ .

Rescheduling will be handled in a same matter. Options of cancellation prior to 24 hours of schedule appointment time: -call our office -email directly. Do not use email sent by unified practice. -text us at 571-699-8428 Thank you for your understanding and cooperation.

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