Insurance Verification Form printable pdf download

Insurance Verification Form

If you would like to see if you supplemental insurance coverage for acupuncture please fill out the

following information. The information on this form will only be shared with your insurance company.

Insurance Company ______________________________________________________

Patient’s Name: ______________________

Date of Birth _____________________

Insurer’s Name: ______________________

Date of Birth _____________________

Member ID #__________________________

Group ID# _______________________

Provider Services Phone Number (on back of card) ______________________________

Claims Address: __________________________________________________________

Patient’s Contact Email ____________________________________________________

When complete, please email this form and a copy of the front and back of your card to:

We will be in contact with the insurance information within 2-3 business days of you submittal.

Thank you for your inquiry and I look forward to working with you!

Insurance Verification Form