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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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, Mar 29
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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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Name of Primary Insurance
(Blue Cross, Aetna, Anthem etc.)
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(HMO, PPO etc.)
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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 the primary policy holder
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Middle Name of the primary policy holder
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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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