Insurance Verification Form (Client)

We are currently in-network with Cigna plans only. Please note that having a Cigna health insurance plan does not guarantee that your acupuncture services are covered.

Please allow 3-5 business days for results which you will receive via the email address you provide below.

Out-of-network plans: EM is not currently filing claims for any out-of-network plans. You will receive a prompt-pay discount on your treatments (see most current fee schedule) and may request a superbill, which you can use to self-file your claims to your insurance plan.

You can find our full policy on insurance here. Please send any additional questions to: admin@energymatterseastbay.com

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Street Address*

City*

State*

Zip*

Date of Birth*

Date

Sex (Please choose the sex listed on your insurance card, as required by our verification system. Your answer will be used solely to verify your insurance coverage, and will not be disclosed or shared as part of your treatment at Energy Matters.)

MF

What type of insurance do you want verified?

Auto Insurance Med PayWorker's CompensationPersonal Health Insurance

My plan is through Cigna

YesNo

Member ID

Group #

Insurance Plan Phone (Can usually be found on the back of the card next to "Providers")

Select if applicable:

Name of primary insured

Date of Injury

Date

Who do we send the claims to?

Your car insuranceThe other driver's insurance

Enter the insurance information for the plan responsible for paying for treatments.

Name of insurance carrier

Claim number

Adjustor Name

Adjustor Phone Number

Policy Number

You have selected Worker's Compensation.

Please have your adjustor send your approval to Medrisk - Phone: 800-225-9675; Fax: 877-455-4440. Once they've received the approved authorization, Medriskl call our office directly to schedule your acupuncture appointments.

Email us at info@energymatterseastbay.com if you have any additional questions.

Unfortunately we are not in network with your plan. We can charge you our prompt-pay discounted fee and offer you a superbill (a more detailed receipt with treatment and diagnosis codes) which you may turn in to your plan for reimbursement provided acupuncture is a covered benefit, you have met your deductible, and your treatment meets any medical eligibility requirments your plan has. Your plan may have other requirments - please give your plan representative a call to determine your actual acupuncture benefits.

Please email us at info@energymatterseastbay.com if you have any additional questions.

Date of next appointment (Leave blank if you do not have an appointment scheduled)

Date

Additional Notes

EM Insurance Verification Form (IVF)