Swiss Acupuncture and Integrative 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

We accept Aetna Anthem BCBS Coordinated Care First Choice Health Group Health/Kaiser PPO plans only Humana Lifewise Premera Regence Triwest/Veteran’s Choice United Health Care CHPW PIP (Personal Injury Protection) and Auto Accidents This is not an exhaustive list, we may accept other insurances. If you want to verify your insurance coverage, please make an appointment for an initial acupuncture visit or for a free consultation with us first. Please make sure to fill in your latest health insurance information during the online scheduling. Please provide us with your insurance information at lease 7 days prior so we are able to let you know what coverage your insurance offers for our service.

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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