Insurance Verification Form

Acupuncture

Your Name (required)

Your Email (required)

Your Phone (required)

Your Address

Date of Birth

Insurance Company

Insurance Member ID

Primary Insurer's Name

Primary Insurer's Birth Date

For personal injury claims, please answer the following:

Claim Adjuster's Name

Claim Adjuster's Phone

Additional Comments

Verify Your Insurance Coverage

Verification of your insurance plan is a courtesy, and can not be guaranteed. We urge you to be proactive with your insurance plan and call the number on the back of the card to see what is covered under your plan. Usually, that information may be obtained by you in a much faster and convenient way. Verification of insurance does not guarantee coverage of acupuncture benefits

Unless insurance is verified ahead of time, the time-of-service cash rate will be charged. If one finds they have benefits after their first visit, they will have a credit towards future copays.

For More Information, Contact:
Advanced Billing Pro, Inc
6520 Japatul Vista Lane
Alpine, Ca 91901

Contact: Jennifer Nichols
Email: jennifer.abpro@gmail.com
Phone: 619-244-8215
Fax: 1-855-426-8566

Please submit all insurance information in the Insurance Verification Form below. Please only call the number above if you are a current patient and have questions about your plan or billing.

San Francisco Health Plan

East-West is a SFHP (San Francisco Health Plan) provider. Eligible patients receive two visits per month for a total of 24 visits per year. Patients must be in the Group: Medi-cal, and in network with either Community Health Network or UCSF.  Participating practitioners are Antonella Soldaini, Stephanie HaneyAdam Okerblom, and Courtney Moore. Please check your plan for requirements for acupuncture visits. Massage is not covered, only acupuncture. Patients can only see the three practitioners listed above. Call us to schedule an appointment: (415) 585-1990.

Referring Clinics:

Please fax your referral to 415-508-9334. Thank you!

Forms

Acupuncture Forms
Acupuncture -New Patient Fertility Forms Female
Acupuncture -New Patient Fertility Forms Male
Acupuncture – New Patient Forms
Acupuncture – Pediatric Form

Massage Forms
Massage Intake Form
Mayan Abdominal Therapy Initial Intake Forms — ***Please note that you must fill out forms and email to tracemar@icloud.com at least 24 hours before your appointment. If forms are not received, the appointment will be auto-canceled and will need to be rescheduled. Thank you for your understanding and cooperation on this matter.

Physical Therapy Form
Physical Therapy – Initial Form

Payment Form
Patient Payment Agreement