Stratford Acupuncture & Wellness Center

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Reason for visit

Patient name

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Available times

Sun, Aug 9

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Mon, Aug 10

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Tue, Aug 11

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Wed, Aug 12

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Thu, Aug 13

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Fri, Aug 14

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Sat, Aug 15

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Insurance verification

Insurance Information

We are currently in-network with Cigna, and will soon be in-network with United OPTUM. We also take insurance that we are out-of-network in if you have out-of-network acupuncture coverage with your plan. Your HSA and FSA dollars are also accepted here. At this time, Medicaid and Medicare/HUSKY do not offer any coverage for acupuncture and are not able to be billed for any treatment.

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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