Acupuncture Insurance Verification Form

Our office is staffed with an insurance billing manager that is specifically trained to determine if our services would be covered by your particular Insurance policy. We have successfully processed claims from Insurance companies such as United, Cigna, Aetna, Blue Cross / Blue Shield, Empire and Humana to name a few.

Should your policy ineligible, we offer cash discount rates for payment at time of the office visit. Please schedule a ten minute complimentary consultation to discuss a cash treatment plan.

Click here to download a PDF version of the Insurance Verification Form to be filled out and faxed back.

Privacy policy

By submitting this form, I understand that my personal information will be used initially for the insurance verification process. Once a scheduled consultation and treatment has been conducted, your information may be used for billing your insurance company for payment of services rendered. The information will be accessible to Tony Willcox, his staff and/or to a third-party biller. I understand that I have the right to request any and all restrictions with the use and disclosure of my health information.


Patient First Name	Patient Last Name


Patient Address


Zip Code	Patient Phone Number

	Male Female
Patient Date of Birth	Gender


Patient Subscriber/ID Number	Group Number

	Single Married Other
Insured Name & ID Number (if different from patient)	Relationship to Insured


Insurance Company Name	Insurance Company Phone Number

	HMO POS	PPO Other
Claim Number (if an auto accident or workman's comp)	Which Policy Do you have?


How did you hear about us?	Date of Accident Injury


Other Info