Order Number 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 * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 * Aetna CareFirst BlueCross BlueShield Cigna Humana UnitedHealth Other Patient's Relationship to Insurance Holder * Self Spouse Child Other 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.