Insurance Request Form printable pdf download

Insurance Request Form

CONFIDENTIAL INSURANCE COVERAGE REQUEST FORM

The information on this form is confidential and will only be divulged to your insurance

company. Please do not list your social security number. If you have any questions, please

Patient Name:__________________________ Date:_____________________

Patient Insurance ID#:___________________

Patient Birthdate:___________

Name of Insured:_______________________

Insured Birthdate:__________

Insured Insurance ID:#___________________ Name of Employer:_________

Name of Insurance Company:_____________

Type of Plan:______________

Group ID#:________

Eligibility Phone # (on back of card):___________________

Address to send claims to: (on back of card)________________________________

___________________________________________________________________

Is there another health benefit plan? If yes, please fill out the information below:

Patient Name:__________________________ Date:_____________________

Patient Insurance ID#:___________________

Patient Birthdate:___________

Name of Insured:_______________________

Insured Birthdate:__________

Insured Insurance ID:#___________________ Name of Employer:_________

Name of Insurance Company:_____________

Type of Plan:______________

Group ID#:________

Eligibility Phone # (on back of card):___________________

Address to send claims to: (on back of card)________________________________

___________________________________________________________________

Please complete and fax this form to our office at (760) 635-0587.

(please check one)

___ Please call me at: ____________________________ with the results of the eligibility check.

___ Please email me at: ___________________________ with the results of the eligibility check.

Acupuncture Continuum, Inc.,

317 N. El Camino Real, Ste. 401, Encinitas, CA 92024 | (760) 635-0581 (phone) (760) 635-0587 (fax)

Insurance Request Form