Verification of Benefits *
In order for us to send your benefits for a full verification of cost, deductible, etc.. - we need to know that you have acupuncture benefits. If you have not done this, please call the number on the back of your card to confirm first, then fill out this form.
Name *
Name
Phone # *
Phone #
DOB *
DOB
Insurance Customer Service Phone # (on back of card) *
Insurance Customer Service Phone # (on back of card)
How would you like to be contacted once we confirm? *