Acupuncture Insurance Verification Form
Dr. Kelsi Sando, DACM, L.Ac.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
How would you like us to contact you after we've verified your insurance?
*
Please Select
Email
Phone Call
Text Message
Insurance Information
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone No
Subscriber's Name (if different than self)
First Name
Last Name
Subscribers Date of Birth (if different than self)
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
Subscriber's Name (if different than self)
First Name
Last Name
Subscriber's Date of Birth (if different than self)
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
Notes
Submit
Should be Empty: