Insurance

Company

To determine your acupuncture benefits, please complete Healthy Roots Medicine's secure insurance verification form:

Please choose the Healthy Roots Medicine office location you would like to be seen at: *

Bethesda Clarksburg Frederick

First Name *

Middle Initial

Last Name *

Address *

City *

State *

Zip Code *

Phone Number *

E-mail *

Patient's Date of Birth *

Gender *

Male Female

Marital Status

Single Married Divorced Widowed

Fulltime Student

Yes No

Employment Status *

Fulltime Part-time Unemployed

Employer Name *

Employment Position

Primary Insurance *

Patient's Relationship to Insurance Holder *

Policy # / Member ID # *

Group #

Insurance Phone Number *

Please provide medical provider phone number on back of card.

Patient Consent: *

My signature below acknowledges, authorizes, and agrees:

1) Healthy Roots Medicine (HRM) to render treatment and apply for benefits. 2) Payment of medical benefits directly to HRM. 3) The release of any medical or other information necessary to process claims. 4) HRM has in-network provider contracts with Aetna, CareFirst (BCBS), Cigna, Humana and United Healthcare companies, and we will bill them as a service to the patient. As the responsible party, you are responsible if your insurance company declines to pay for any reason.