Insurance Verification Form
Please allow 3-5 business days for verifications to be processed.
Please check the services for which you want benefits verified:
Acupuncture
Nutrition counseling
Both acupuncture and nutrition counseling
I want information on how to submit claims myself for therapeutic massage services
Patient Information
Enter your information here
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Non-binary
Other
Gender
Insurance Information
Enter the policyholder's information here
Primary Insurance Company
*
Please Select
BCBS
United Healthcare Company
Cigna
Aetna
BCBS includes all States, Anthem, Premera
Insurance Company Phone Number
*
Usually found on back of insurance card
Subscriber or Member Number
*
Group Number
*
Policyholder's Relationship to Patient
*
Please Select
Self
Spouse
Domestic Partner
Other
Policyholder's Name
*
First Name
Last Name
Policyholder's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policyholder's Date of Birth
*
-
Month
-
Day
Year
Date
Policyholder's Gender
*
Please Select
Female
Male
Nonbinary
Other
Insurance Card (Front)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Card (Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Notes
Save
Submit
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