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  • Tend Natural Health is committed to providing the best care for patients. As a service, we bill insurance carriers directly. However, patients are responsible for all charges resulting from treatment by their provider. We require patients to check benefits before their first treatment. It is the patient's responsibility to be aware of her/his benefit coverage, deductible, co-pay, and coinsurance amounts. We ask that you fill out this form to the best of your knowledge.
  • Date of Birth:
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  • Please call the customer service number from the back of your ID card and ask the following questions:
  • Call Date:
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  • What is the date my coverage began?
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  • Does my policy cover ACUPUNCTURE?
  • Is this provider (Kathryn Sydney, L.Ac.) listed as
  • 1. Is this provider listed as "In network" at 4531 SE Belmont Ave, Suite 313, Portland, OR 97215.
  • 2. If "out of network," will my policy cover services performed by this provider?
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  • 3. Will these services be applied toward my deductible?
  • 5. Is there a maximum visit or amount per year for this service
  • 6. Is this a combined benefit?
  • Is a NATUROPATHIC PHYSICIAN an allowed provider type on this plan?
  • Is this provider (Kathryn Sydney, ND) listed as "In network" "Out of network"
  • 3. Is compounding a medical benefit?
  • 5. Will these services be applied toward my deductible?
  • 7. Is there a maximum visit or amount per year for this service
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  • TEND
    natural health
  • Do I have a coinsurance?
  • Does my insurance require a referral from my PCP for any of the above services?

  • Assignment of Insurance Verification and Benefits Acknowledgement

  • I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage by my insurance company, and that I am financially responsible for all services rendered to me by Tend Natural Health.

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