Shere Family Acupuncture

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Reason for visit

Patient name

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Available times

Sun, Jan 20

No availabilities found on this day.

Mon, Jan 21

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Tue, Jan 22

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Wed, Jan 23

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Thu, Jan 24

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Fri, Jan 25

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Sat, Jan 26

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Insurance verification

Insurance Information

As of April 1st, 2018 we will begin accepting insurance and direct billing, pending verification of benefits. We are an out of network provider working with the following insurance companies: Cigna, BCBS of VT and BCBS of NY/Excellus, Aetna, Commercial Travelers, (a student health care plan through Middlebury College), and Harvard Pilgrim.

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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