Acupuncture Restorative Center

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Appointment details

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Reason for visit

Patient name

Email address

Phone number

Available times

Fri, May 20

No availabilities found on this day.

Sat, May 21

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Sun, May 22

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Mon, May 23

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Tue, May 24

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Wed, May 25

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Thu, May 26

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Fri, May 27

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Sat, May 28

No availabilities found on this day.

Insurance verification

Insurance Information

*PLEASE READ*: If you would like your my office to verify your insurance benefits *BEFORE* your appointment, please make sure to fill out the patient insurance information COMPLETELY. Without this information completed, my insurance billers can not verify if you have acupuncture coverage or not. If you do not fill this information online before your appointment, I can collect the information during your appointment time, however verification of coverage takes at least a few days to complete, thus you will need to pay for your visit in full until It can be determined if you have coverage or not. This includes ALL OF THIS INFO: Your name, date of birth, *ADDRESS* (people sometimes leave this blank), telephone number, email address, Insurance Company, Member ID, Group ID, Insurance type (PPO, HMO, etc.) and Insurance company phone number (Provider number if listed on your insurance card, otherwise Member service number).

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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