Medical Insurance Verification Form

Medical Insurance Verification Form

Enter your personal details and insurance information to help verify coverage before your appointment. Anchor Point Acupuncture may be in-network with your insurance
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Insurance Provider
Medical Insurance Member ID
Medical Group Number
Secondary Insurance Information (optional)
Medical Insurance Card Upload (optional)

Cancelof
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Out-of-Network Care. Anchor Point may not be in-network with your plan, and that doesn't keep you from care. You can still see me as an out-of-network provider. Pay at the time of visit, and you'll leave with a superbill to submit for reimbursement. Your plan sets the course on what it covers, so chart it before your first visit.

Questions to ask your insurer (number is on your card):

☐ Do I have out-of-network benefits for acupuncture? ☐ Yes ☐ No
☐ Out-of-network deductible: $______ Met so far: $______
☐ Percent reimbursed: ______%
☐ Visit limit or annual cap: ______
☐ Referral or prior authorization needed? ☐ Yes ☐ No
☐ Rep name / call reference #: __________________
Should be Empty: