Our office participates with CareFirst Blue Cross Blue Shield (BCBS), Aetna and United Healthcare companies and their subsidiaries. Insurance IntakeFull Legal Name(Required)Preferred NameAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth(Required) Month Day Year Phone(Required)Email(Required) How would you like us to contact you with the information we receive from your insurance company regarding your acupuncture benefits and coverage?(Required) Email Phone Is the reason you are coming related to Workers Comp, Auto Accident or Personal Injury case?(Required) Yes No Our office does not process to your personal health insurance for Workers Comp, Auto Accident or Personal Injury related cases unless you provide a Letter of Subrogation from your insurance company or a PIP exhaust letter to our office. If you are unable to provide that to our office, you will be required to pay the self-pay rate at each appointment and we will not process your claim to your insurance. We can give you the appropriate supporting documents to seek reimbursement on your own. If you have any questions or would like to speak to someone further, please call our main number at 301-620-1414 and leave a voicemail with our Insurance Team or email insurance@hhamd.com. Primary InsuranceInsurance Company Name(Required)Member ID#(Required)Group #/Enrollment Code(Required)Policy Subscriber's Name(Required)Subscriber's DOB(Required) Month Day Year Patient Relationship to Subscriber(Required) Self Spouse Child Partner Other Provider Service's Phone #(Required)Secondary InsuranceMember ID#Group #/Enrollment CodePolicy Subscriber's NameSubscriber's DOB Month Day Year Patient Relationship to Subscriber Self Spouse Child Partner Other Provider Service's Phone #**Please provide us with your insurance card(s) for claims filingMax. file size: 128 MB. Provider to render services and bill my insurance company for those services Payment of medical benefits directly to Provider. The release of any medical or other information necessary to process this claim As the responsible party, I am financially responsible if my insurance company declines to pay for any reason, my credit card on file will be charged for any balances beyond 30 days.Our office will obtain an insurance benefits quote for you. An insurance benefits 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.Signature of Patient, Legal Representative, or Parent/Guardian(Required)Date(Required) Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian(Required)Relationship to Patient Insurance IntakeFull Legal Name(Required)Preferred NameAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of Birth(Required) Month Day Year Phone(Required)Email(Required) How would you like us to contact you with the information we receive from your insurance company regarding your acupuncture benefits and coverage?(Required) Email Phone Is the reason you are coming related to Workers Comp, Auto Accident or Personal Injury case?(Required) Yes No Our office does not process to your personal health insurance for Workers Comp, Auto Accident or Personal Injury related cases unless you provide a Letter of Subrogation from your insurance company or a PIP exhaust letter to our office. If you are unable to provide that to our office, you will be required to pay the self-pay rate at each appointment and we will not process your claim to your insurance. We can give you the appropriate supporting documents to seek reimbursement on your own. If you have any questions or would like to speak to someone further, please call our main number at 301-620-1414 and leave a voicemail with our Insurance Team or email insurance@hhamd.com. Primary InsuranceInsurance Company Name(Required)Member ID#(Required)Group #/Enrollment Code(Required)Policy Subscriber's Name(Required)Subscriber's DOB(Required) Month Day Year Patient Relationship to Subscriber(Required) Self Spouse Child Partner Other Provider Service's Phone #(Required)Secondary InsuranceMember ID#Group #/Enrollment CodePolicy Subscriber's NameSubscriber's DOB Month Day Year Patient Relationship to Subscriber Self Spouse Child Partner Other Provider Service's Phone #**Please provide us with your insurance card(s) for claims filingMax. file size: 128 MB. Provider to render services and bill my insurance company for those services Payment of medical benefits directly to Provider. The release of any medical or other information necessary to process this claim As the responsible party, I am financially responsible if my insurance company declines to pay for any reason, my credit card on file will be charged for any balances beyond 30 days.Our office will obtain an insurance benefits quote for you. An insurance benefits 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.Signature of Patient, Legal Representative, or Parent/Guardian(Required)Date(Required) Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian(Required)Relationship to Patient
