Active Life Acupuncture and Wellness Center

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Reason for visit

Patient name

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Phone number

Available times

Fri, Feb 26

No availabilities found on this day.

Sat, Feb 27

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Sun, Feb 28

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Mon, Mar 1

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Tue, Mar 2

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Wed, Mar 3

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Thu, Mar 4

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Fri, Mar 5

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Sat, Mar 6

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Insurance verification

Insurance Information

For information of filing your appointments through medical, major medical, personal injury or workers compensation insurance, please visit the Pricing section of acupuncturefayetteville.com, scroll to the bottom, and click on the Verify Your Insurance button to fill out your insurance information. We will contact you when we hear about your coverage. We also accept FSAs (Flexible Spending Accounts) and HSAs (Health Savings Accounts). CareCredit does not currently cover acupuncture.

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

I have read and accept the Terms of Use and Privacy Policy

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