Insurance Benefits Check

We are happy to run a free benefits check with your insurance provider to help guide you to better understand your acupuncture coverage under your insurance plan. Please fill out the following form and we will return the information to you based on your preference provided.

BENEFITS CHECKS CAN TAKE UP 3-5 BUSINESS DAYS TO PROCESS

Which Location Will You Be Visiting?*
- Frederick
- Boonsboro
Name*
First Last
Phone*
we may need to reach you to verify information for the insurance company.
Email*
Date of Birth*
MM slash DD slash YYYY
Insurance Company
Insurance Member ID#
Group #/ Enrollment Code
Provider/ Member Services #
Subscriber Name
Subscriber Date of Birth
MM slash DD slash YYYY
Do you have secondary insurance?
- No
- Yes
Secondary Insurance Co.
For Secondary Insurance
Secondary Ins. Member ID
For Secondary Insurance
Secondary Group #/Enrollment Code
For Secondary Insurance
Secondary Provider/Member Services #
For Secondary Insurance
Secondary Subscriber Name
For Secondary Insurance
Secondary Subscriber Date of Birth
MM slash DD slash YYYY

For secondary Insurance
Are you on Medicare?
- No
- Yes
Medicare member #
Upload a Copy of your Insurance Card
Max. file size: 20 MB.
How would you like us to contact you with the information we receive from your insurance company regarding your benefits and coverage?
- Email
- Phone
A quote is an estimation of coverage - we are just the messenger! Please keep in mind that the information relayed to you is a quote our office has received directly from your insurance company. It is designed as a courtesy to you, to help provide an estimation of what to expect from your coverage. It is not a guarantee that your insurance will pay your claims or that all quoted information is final. Your insurance policy is a contract between you/your employer and the insurance company - our office is not party to that contract. Although it is rare, sometimes your final coverage determined during claims processing can differ from the information relayed originally. Please be aware that some and perhaps all of the services provided may be considered non-covered or denied under your plan based on the limitations in your policy. Any non-covered or denied services will become your full financial responsibility as outlined in our Financial Policy. Please read your Evidence of Coverage booklet that you received from your insurance company as to what types of services are not covered under your policy or contact your insurance company directly if you have specific questions about your coverage.
Email
This field is for validation purposes and should be left unchanged.

Please be sure to have your Credit Card Authorization submitted.

Credit Card Authorization