Insurance Eligibility Request Form

Please fill out the following information to check your acupuncture eligibility and coverage on your insurance policy. Most of the information should be found on your insurance card. "Insured Name" is the primary account holder for the insurance policy and could be the same as or different than the "Patient Name".

We will contact you within 24-48 hours with a summary of your coverage. Thank you!

**Please note that we are not contracted with any HMO plans. Only PPO plans have the potential for benefits.**

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