Swiss Acupuncture and Integrative Medicine

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Available times

Thu, Jan 21

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Fri, Jan 22

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Sat, Jan 23

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Sun, Jan 24

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Thu, Jan 28

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Fri, Jan 29

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Sat, Jan 30

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Insurance verification

Insurance Information

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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.)

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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

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Date of accident Please bring your authorization form to the office

Case/Claim #

Case Manager's Name

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Address to submit claims

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Case/Claim #

Employers Name

Employers Address

Insurance company name

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