Please print out the following and bring it in with you on your first visit.

VERIFICATION OF INSURANCE COVERAGE FOR ACUPUNCTURE

This form MUST be filled our COMPLETELY and returned to us before we can bill your insurance company for our services. Until then, full payment will be required at the time of service. For most health insurance, there will be a percentage of charges not covered for which payment will be required at the time of service. BRING this completed verification form to the office.
Please NOTIFY US when your insurance coverage or employment changes.

Patient’s name
_______________________________________________________________
Social Security # ____________________________
Date of injury/onset _____________
If the insured person is other than the patient, please fill in the following information:
Name of insured person __________________________
Social Security # _____________
Insured’s address__________________________________________________________
                                street                                              city                              state           zip
Insured’s date of birth ________________________ Home phone __________________
Insured’s employer’s name ___________________________________________________
Type of insurance: (circle) Group health through employer / Auto medical pay / HMO / other:
Is there more than one policy that covers the patient? Yes / No
If so, who is that carrier? _____________________________________________________

P LEASE READ AND SIGN BELOW
Authorization to release information:
I authorize the release of any medical or other information necessary to process this claim. A photostat of this authorization shall be as valid as the original.
Patient’s or guardian’s signature _______________________________ Date __________
Assignment of insurance benefits:
I authorize payment of medical benefits directly to Diane L. Smalley, L. Ac. for the services described on the attached insurance claim. A photostat of this authorization shall be as valid as the original.
Patient’s or guardian’s signature _______________________________ Date __________

CALL YOUR INSURANCE COMPANY AND ASK THEM THE FOLLOWING QUESTIONS:
(You may find some of this information on your card.)
Date called ____________________ Phone # ________________________________________
1.Name of person who gave information? _____________________________________________
Does my policy cover acupuncture? (circle) Yes No If not, stop here. If yes, continue:
2. Full name of insurance company? ________________________________________________
Name of insurance plan? ________________________________________________________
Mailing address for claims? ______________________________________________________
Street or P.O. Box __________________________________________
City_________________________________________State_____________Zip_____________  
      

Your name again (this will print as page 2)___________________________________________

Attn: Policy Number? ______________________________
Group Number? __________________________________
Claim Number? ___________________________________
Other? __________________________________________
What is the effective date of my policy? ___________________________
3. Is authorization required prior to treatment? (circle) Yes No
If so, what are their special phone numbers or departments to call?
_____________________________________________________________________ _____________________________________________
Name and number of person in charge of my claims (if applicable, e.g., attorney in cases of auto-medical pay)?
____________________________________________________________________________
4. (Insurance companies usually pay either a Maximum or a Percentage of the treatment.) Is there a Maximum payment per treatment OR do you pay a Percentage? (circle) Maximum (see a. below) Percentage (see b., c. & d. below)
a.) If a maximum per treatment, what amount? $ __________
b.) If a percentage is paid, how much is it? ___________ %
c.) Does the percentage change? (circle) Yes No
d.) What is the percentage for accidents (if applicable)? __________ % 5.
What is the deductible amount? $ __________ Is that per year? $ __________
–OR– Per condition? $ __________
–OR– Per family member? $ ___________
How much of the deductible has been paid? $ _________ (Remainder is $____________ )
6. Are there any limits to the coverage? (circle) Yes No
Is there a limit to the number of visits allowable? (circle) Yes No
If so, what are they? (circle) per year per diagnosis other _________________
Are there any other limits? _____________________________________________________________
7. Do you send payment directly to my acupuncturist with authorization? (circle) Yes No