This form is used to verify details necessary to determine what benefits you may have.
You will receive a call when we have obtained this information .

Many insurance companies now pay for acupuncture treatments. Should your insurance company not cover this therapy, The Balance Health and Wellness Center is contracted with most insurance companies to provide a discounted rate. Enter your information below and we will gladly qualify your insurance for you. Be sure to include the best contact number should we need more information.

*NOTE you most complete each box below to submit the form correctly*

Insurance Form

Today's Date (*)

Patients Name (*)

Date of Birth MM/DD/YYYY (*)

Address (*)

Primary Card Holder (if different from patient) (*)

Primary Card Holder Birthdate (*)

Phone Number (*)

Email (*)

Insurance Carrier

Insurance ID Number (*)

Chief Concern

Insurance Customer Service Number (*)

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