Lion's Heart - Dr. Kim Peirano, DACM, LAc

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Reason for visit

Patient name

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Available times

Wed, Jun 3

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Thu, Jun 4

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Fri, Jun 5

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Sat, Jun 6

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Insurance verification

Insurance Information

Dr. Kim Peirano is an in-network provider with TriWest VA and select Blue Shield plans. She also accepts other PPO type insurance plans with out-of-network coverage. Please submit your insurance plan details so that we may verify your coverage and benefits before your appointment. Patients who do not have adequate insurance coverage are subject to the full posted rate due at time of service. Any missed appointments are subject to the full late fee, as this cannot be billed to your insurance.

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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