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Acupuncture Health For Life
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RANDOLPH, HAI LUA PLAZA
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Adjunctice Acupuncture
Community Acupuncture
Duration:
minutes
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Thanh Pham
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Insurance verification
If you want to use insurance for your visit please fill out the fields below so that we can verify your coverage
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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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Insurance Provider Phone Number
Located on back of insurance card
Claim address
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Covered under someone else's insurance plan?
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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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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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Date of injury
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Case/Claim #
Employers Name
Employers Address
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