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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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Fri
, Nov 27
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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
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
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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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Patient relationship to insured
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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
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Date of injury
Please bring your authorization form to the office
Case/Claim #
Employers Name
Employers Address
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