Essential Health Acupuncture

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Reason for visit

Patient name

Email address

Phone number

Available times

Wed, Oct 20

No availabilities found on this day.

Thu, Oct 21

No availabilities found on this day.

Fri, Oct 22

No availabilities found on this day.

Sat, Oct 23

No availabilities found on this day.

Insurance verification

Insurance Information

As a courtesy, we will accept an assignment of insurance benefits. This means that we will be responsible for billing your insurance and providing any additional information that may be requested. The patient portion (co-pay or coinsurance) of the bill is due at the time of service. YOU MUST E-MAIL A COPY FRONT/BACK OF YOUR INSURANCE CARD WITH DRIVER'S LICENSE TO FRONTDESKEHA@GMAIL.COM 2 BUSINESS DAYS BEFORE YOUR APPOINTMENT. If we cannot verify your insurance benefits before your appointment we will collect a $90 retainer fee that can be applied toward the cost of services, copays, coinsurance or any other costs incurred with any non-used funds available for refund. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you, your employer and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be deemed "non-covered" services (not considered reasonable and necessary under the insurance program). It is your responsibility to familiarize yourself the terms and conditions of your policy (such as how many treatments per year, the reimbursement rates, and your copay/coinsurance) as we cannot be responsible for knowing the terms of each patient's coverage. We will assist you in every way possible to obtain the maximum benefit from your plan.

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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