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Wilder Health
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Wilder Health
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Acupuncture
Herbal Consultation
Duration:
minutes
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Hopi Jane Wilder
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, Jun 20
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, Jun 26
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Insurance verification
Insurance Information
I accept VA/Triwest insurance, Personal Injury, Work Comp, Providence, Regence, Blue-Cross Federal and Aetna.
If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage
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yes
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Name of Primary Insurance
(Blue Cross, Aetna, Anthem etc.)
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(HMO, PPO etc.)
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The ID number on your insurance card
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Located on back of insurance card
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Covered under someone else's insurance plan?
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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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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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Date of injury
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Case/Claim #
Employers Name
Employers Address
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