PhoneTo 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 -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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. Insurance Card Image Add Files Please upload the front and back images of your insurance 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.