Edelweiss Acupuncture LLC

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Appointment details

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Reason for visit

Patient name

Email address

Phone number

Available times

Tue, Jul 23

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Wed, Jul 24

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Thu, Jul 25

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Fri, Jul 26

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Sat, Jul 27

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Insurance verification

Insurance Information

If you have acupuncture benefits and would like to use them, please bring your insurance card at the time of your appointment. If you would like your benefits and eligibility to be verified in advance, please call or email and provide a picture of the front and back of your insurance card and your date of birth.

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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