Insurance Form

Please note we only accept insurance for acupuncture. Most insurance companies require a diagnosis of chronic lower back pain. Medicare will only cover chronic low back pain. It is important to mention that acupuncture treatment can promote healing over the whole body.

Insurance Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Chief Complaint(Required)

Primary Insurance

Insurance Company Name

Policy # or ID

Group # or ID

Insurance Phone #

Secondary Insurance

Insurance Company Name

Policy # or ID

Group # or ID

Insurance Phone #