Venn Acupuncture

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Patient name

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Available times

Sat, Sep 23

No availabilities found on this day.

Sun, Sep 24

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Mon, Sep 25

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Tue, Sep 26

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Wed, Sep 27

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Thu, Sep 28

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Fri, Sep 29

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Sat, Sep 30

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Insurance verification

Insurance Information

PAYING WITH INSURANCE: • If you'd like to pay with insurance, please fill-out your insurance information. We will inform you of your acupuncture benefits on the day of your appointment. • As a courtesy, we will bill your insurance carrier. However, it must be understood that the contract is between you and your insurance and you are fully responsible for any amount that they do not pay, including deductibles and co-insurance. • Verifying benefits is not a guarantee of payment. If for any reason a submitted claim is denied by your insurance, you will be responsible to pay the full billed amount. • Co-pays will be due at time of service. • By initialing here, you agree to the release of medical and billing information necessary for treatment, payment and healthcare operations and assign benefits payable to Venn Acupuncture and/or Claudia Venn

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

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