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Jenny Tu Acupuncture
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99Barbell
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Acupuncture
Free Consultation ACU-FIT
Free Consultation-Acupuncture
Duration:
minutes
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Jenny Tu
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Mon
, Feb 17
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Tue
, Feb 18
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, Feb 19
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, Feb 20
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, Feb 21
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Sat
, Feb 22
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Insurance verification
Insurance Information
For patients who are using insurance, please book a day or more ahead of time to make sure your care will be covered. You will receive a call or email for confirmation of your insurance and appointment.
If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage
Choose
yes
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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
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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
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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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Yes
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Date of injury
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Case/Claim #
Employers Name
Employers Address
Insurance company name
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