Fujii Acupuncture & Herbal Medicine

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Reason for visit

Patient name

Email address

Phone number

Available times

Sat, Sep 26

No availabilities found on this day.

Sun, Sep 27

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Mon, Sep 28

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Tue, Sep 29

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Wed, Sep 30

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Thu, Oct 1

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Fri, Oct 2

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Sat, Oct 3

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Insurance verification

Insurance Information

Currently we accept personal injury for motor vehicle accidents, Regence, Blue Cross, Premera, Lifewise, Aetna, Group Health PPO (not HMO) and United or other insurance plans with Out-of-network benefits. Please verify your insurance before your appointment.

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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