Middleway Medicine

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Reason for visit

Patient name

Email address

Phone number

Available times

Fri, Dec 3

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Sat, Dec 4

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Sun, Dec 5

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Mon, Dec 6

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Tue, Dec 7

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Wed, Dec 8

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Thu, Dec 9

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Fri, Dec 10

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Sat, Dec 11

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Insurance verification

Insurance Information

**If you are a new patient, please call the clinic to schedule your initial visit.** We participate* with these insurance companies: First Choice HMA MODA Pacific Source Providence Regence/ BCBS, Regence Med Advantage Triwest 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

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

I have read and accept the Terms of Use and Privacy Policy

Text me a reminder and other helpful updates*

*By providing your telephone number to Unified Practice you agree that a representative of Unified Practice and/or contracting clinics can place calls or text messages to the number provided, including appointment reminders and telemarketing, using an automatic telephone dialing system or an artificial or prerecorded voice. Your consent is not a condition of using or purchasing our goods or services.

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