Affinity Acupuncture, PLLC

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Reason for visit

Patient name

Email address

Phone number

Available times

Tue, Sep 21

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Wed, Sep 22

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Thu, Sep 23

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Fri, Sep 24

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Sat, Sep 25

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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, GEHA, Pacific Source, and United Healthcare insurances. *Medicare and Medicare Supplement Plans do NOT currently cover acupuncture.* 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. 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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