UprightQi NYC

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Reason for visit

Patient name

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Phone number

Available times

Wed, Apr 14

No availabilities found on this day.

Thu, Apr 15

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Fri, Apr 16

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Sat, Apr 17

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Insurance verification

Insurance Information

All out-of-network insurance is accepted. If you are unsure if your insurance covers out-of-network acupuncture, No problem! We'll find out for you. Payment at time of treatment is required until insurance is verified. Patients assume full responsibility for any remaining balance left uncovered by their insurance. The clinic reserves the right to decline any insurance plan which poses an undue administrative burden or logistical challenge to the operations of the practice without sufficient compensation. In these cases, a superbill is issued directly to the patient so that they may submit it for reimbursement purposes. Any further questions regarding insurance are welcome at your next session.

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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