Insurance Verification

Verify Your Acupuncture Coverage

Please fill out this form, and upload your photo ID, health insurance card (front & back) for reference. We will verify your acupuncture and massage therapy benefits with your insurance company and get back to you in 3-5 business days.

A Estimate Cost of Care / Payment Arrangement will be emailed to you if your insurance does not cover our treatments.

*The use of this form to communicate with GoodPoint Medicine PC will not establish a doctor-patient relationship with the medical office or any healthcare provider at the office. The form IS HIPAA compliant. If the information is time-sensitive, please call our office directly.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Health Insurance Company Name *

Plan Name *

Health Insurance Member ID *

Group Number *

Insurance Provider Phone Number: *

Date of Birth *

Your reason for visit: neck pain, lower back pain, stress, fertility issue, etc. and/or other comments: *

Photo ID and/or Insurance Card (front) *

Max file size: 20MB

Insurance Card (Back) *

Max file size: 20MB

Preferred Contact Method *

Submit

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Verify Your Acupuncture Coverage

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