Affinity Acupuncture, PLLC

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Patient name

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Phone number

Available times

Wed, Oct 21

No availabilities found on this day.

Thu, Oct 22

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Fri, Oct 23

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Sat, Oct 24

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Insurance verification

Insurance Information

Many insurance policies cover acupuncture, but I do not claim that yours does. Affinity Acupuncture currently accepts Aetna, Allegiance, Blue Cross Blue Shield, Cigna, EBMS, Pacific Source, and United Healthcare insurances. Please contact the office if you have any questions about insurance coverage. Fill out the information below, and we will be happy to verify acupuncture benefits. Bring a copy of your insurance card to your visit so a copy can be made for your record. Please understand that ultimately you are responsible for all treatment charges if insurance will not cover the cost of acupuncture treatment.

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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