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PATIENT INFORMATION

Employer's Name

Name

First Name

Last Name

Social Security Number

Date of Birth

YYYY

Sex

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Others

Preferred Method of Contact

Patient's Phone Number

(###)

###

####

Patient's Email

Chief Complaint / Primary Diagnosis

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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INSURANCE INFORMATION

Insurance Company Name

Phone

(###)

###

####

Policy Number / ID Number

Relationship to Insured

Group #

Policy Holder Name

First Name

Last Name

Policy Holder DOB

YYYY

Subscriber # / ID #

Claim # if an Accident

Date of Accident / Injury

YYYY

ADDITIONAL INFORMATION

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Many health insurance plans in New York City cover acupuncture, including Blue Cross and Blue Shield (BCBS), Aetna, Cigna, United Healthcare (UHC), Oxford and others. Unfortunately, all plans are not the same, and in many cases there are limits or deductibles that must be met before coverage begins.

To find out the details of your coverage, submit your information here and we will get back to you. If you would like to be treated before we receive your verification details, contact us and we will review your options with you.

By submitting this form, the patient understands they are fully responsible for any fees not covered by their insurance and will pay all bills in full by their credit card on file or digital invoice.

Verify Your Insurance

INSURANCE VERIFICATION FORM

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