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Middleway Medicine
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Middleway Medicine
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Follow-Up
Duration:
minutes
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Ann Zimmerman
Richard C Zimmerman
Ryder Kardokas-Johanson
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Please call our office with any insurance company or benefit changes on your health plan.
Insurance verification
Insurance Information
We participate* with these insurance companies: First Choice MODA Pacific Source Providence Regence/ BCBS United Healthcare *participation is not a guarantee of payment At this time, Medicare does not cover acupuncture services.
If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage
Choose
yes
no
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
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Covered under someone else's insurance plan?
Select "yes" if you are covered under someone else's insurance
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Yes
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Patient relationship to insured
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Spouse
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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
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Yes
No
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
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Yes
No
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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