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Acupuncture Restorative Center
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Acupuncture Restorative Center
Appointment details
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Acupuncture (Existing Patient)
Acupuncture (New Patient)
Duration:
minutes
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Rasa Sammy
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Thu
, Sep 24
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, Oct 1
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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.)
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(HMO, PPO etc.)
ID # on insurance card
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Located on back of insurance card
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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
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Address to submit claims
Employment Accident?
Workers Compensation
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Date of injury
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Case/Claim #
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