This is form for permission to bill your Insurance Company and an agreement for payment.

Insurance Billing Consent Form

Acupuncture for Wellbeing LLC
Full Name

First NameLast Name
Plans we are in network with:

United Healthcare/ UMR: Acupuncture & Massage Therapy

Blue Cross/ Blue Shield: Acupuncture

Plans we do not accept:

Medicare: You can only go to Dr. PA or NP. Your supplemental is secondary and WILL NOT WORK.

Aetna, Cigna, all others.

We do our best to offer insurance and to get your claims paid, and they are also never guaranteed.
If applicable:

Preferred NamePreferred Pronouns
Phone Number

Area CodePhone Number
Please fill in your birthday. Month/ Day/ Year
Which service are you seeking? ex, Acupuncture or Massage Therapy
If you are requesting an appointment for Massage Therapy, we ask that you call them first. Then we can make an appointment and we will verify your benefits. The inquiry volume is simply too high for Massage for us to handle. Thank you for understanding.
E-mail
Please Upload the front and back of your Insurance Card. It helps our biller.

Browse Files
I understand that Acupuncture for Wellbeing LLC is Hipaa compliant, Cancelof
My Insurance Provider is blanks*My Insurance ID number is blank*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What are you seeking Treatment for?
Insurance covers a variety of Pain, and Nausea.
Which location are you seeking Treatment for? Arvada or Boulder?
We do not take insurance for Massage Therapy in Boulder. We only accept UHC for Massage Therapy in Arvada.
I agree to pay the full amount of Services rendered, according to the cash rates/ time of service rates of the Practitiioner, if my plan doesn't pay for any reason within 30 days of services rendered, I agree to be charged/ liable for these rates. I will allow/give permission Acupuncture for Wellbeing LLC to bill/submit my information for billing purposes to my Insurance Company. I agree to leave my billing information on file for future use if needed.

DISCLAIMER:

Benefit Check Disclaimer: While we try to be as accurate as possible when verifying benefits, your fees may change depending on your eligibility and benefits during the date of your sessions. This is an estimate as of today, and we won't know your exact fee until we bill your insurance and get your explanation of benefits back from your insurance company. You are also encouraged to call the number on the back of your insurance card and ask your member representative about your 'acupuncture, outpatient, office visit' benefits'. Please let me know if you have any questions about your benefits
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Insurance Billing Consent Form