Insurance Verification Form printable pdf download

Los A ltos A cupuncture C enter

INSURANCE V ERIFICATION F ORM

This f orm i s o nly r equired i f y ou p lan o n u sing h ealth i nsurance. T o d etermine w hether y our i nsurance

provider c overs a cupuncture a nd r elated s ervices, p lease f ax o r m ail t his f orm t o o ur c linic a f ew d ays

before y our v isit s o w e c an v erify y our e ligibility.

Please p rint a ll i nformation c learly.

Patient N ame_______________________________________ D ate o f B irth_______________________

Cell P hone ( ______) _ ______________________ H ome P hone ( ______)__________________________

Email________________________________________________________________________________

Policy H older N ame________________________ B irthdate________ P atient R elation t o H older_______

Policy H older I D____________________ G roup I D________________ E ffective D ate________________

Insurance P rovider________________________________ I nsurance P hone ( _____)_________________

Insurance P rovider A ddress ( Billing)________________________________________________________

□

Are y our s ymptoms a r esult o f

E mployment?

A uto A ccident?

O ther A ccident?

If s o, a nd y ou w ant t o i nclude y our a cupuncture v isits i n y our c laim, p lease p rovide y our

Claim # __________________________________________ C ontact P erson________________________

All fees for medical services are due at the time of visit unless previous arrangements have been made

between Los Altos Acupuncture Center and your insurance provider. Insurance is considered a method

of r eimbursing t he p atient f or f ees p aid t o t he h ealth p rovider a nd i s n ot a s ubstitute f or p ayment. I t i s

your responsibility to pay any deductible amount, co-‐insurance, or any other balance not paid by your

insurance p rovider. N ote t hat a ll p ublished p rices r eflect a c ourtesy d iscount f or c ash p atients.

Signature___________________________________________ D ate______________________________

***********************************OFFICE U SE O NLY***********************************

Deductible ( Individual/Family)____________________________Co-‐Pay___________________________

Paid____________________________ M ax C overage ( Per Y ear)_________________________________

Max O ffice V isit ( Per Y ear)___________ M ax O ut o f P ocket____________________ I n N etwork ( YES/NO)

Other S pecifics_____________________________ L imits o n C omplaints/Diagnosis__________________

Covered T reatments: Office V isit ( 99202)

Acupuncture ( 97811/97810)

Date

Verified b y

Los A ltos A cupuncture C enter | 8 81 F remont A venue S uite A 5, L os A ltos, C A 9 4024 | P hone: ( 650) 9 48-‐8483 |

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Insurance Verification Form