ACUPUNCTURE COVERAGE BY INSURANCE

*HSA, FSA, AND MRA payments have also been accepted.

CHECK YOUR INSURANCE BENEFITS

We are in-network provider for Cigna. We also accept most other PPO insurance plans as an out-of-network provider.

*All information is kept strictly confidential and will only be used for verification purposes with your insurance company.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Full Date of Birth

Insurance Carrier

Member ID#

Please include any letters

Name of Main Policy Holder (if different)

Additional Comments or Questions