Acupuncture Insurance Verification Form
Dr. Kelsi Sando, DACM, L.Ac.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Subscriber's Name (if different than self)
First Name
Last Name
Subscribers Date of Birth (if different than self)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Relationship to Patient
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name (if different than self)
First Name
Last Name
Subscriber's Date of Birth (if different than self)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber's Relationship to Patient
Notes
Submit
Should be Empty: