Insurance Intake Form

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Insurance Coverage & Benefits Check

Thank you for contacting us. We look forward to supporting your health goals. As a courtesy, we will have our biller check the benefits on your insurance policy. You can find most of the information on your insurance card. Information must be received 48 prior to Initial Appointment. Please allow approximately 24 hours on weekdays for notification of your benefits.

Date of request

MonthDayYear

Full Name

First NameLast Name

Gender

Phone Number

Area CodePhone Number

Date of Birth

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

INSURANCE INFORMATION

Note: While Medicare does not currently cover acupuncture, please list it on the form under the primary insurance company.

PRIMARY INSURANCE

Primary Company Name

Policy Holder's Name

Member #

Group #

Provider phone # (on back of card)

Area CodePhone Number

SECONDARY INSURANCE (if applicable)

Secondary Company Name

Policy Holder's Name

Member #

Group #

Provider phone # (on back of card)

Area CodePhone Number

MAIN HEALTH COMPLAINTS

Note: Insurance companies pay for "medical necessity" which is often limited to pain conditions. Please accurately indicate all conditions for which you seek care, with special attention to any acute or chronic pain conditions.

What conditions do you want treatment for? (list in order of importance)

CONTACT INFORMATION

Who and how should we notify of the results?

Name

Phone

Email

Anything else you would like us to know?

Insurance Coverage & Benefits Check