Insurance Verification Form

    Acupuncture

    Your Name (required)

    Your Email (required)

    Your Phone (required)

    Your Address

    Date of Birth

    Insurance Company

    Insurance Company Phone
    (often found on back of card)

    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:

    Christy Young
    Phone: 415-585-1990
    Hours: Tuesdays and Fridays 11:00 am – 2:00 pm

    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 Haney, Shannon Piercy, and Sapho Teologo. Please check your plan for requirements for acupuncture visits. Massage is not covered, only acupuncture. Call us to schedule an appointment: (415) 585-1990.

    Referring Clinics:

    Please fax your referral to 415-859-7543. Thank you!

    Forms

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

    Acupuncture – Formulario en Español

    Massage Forms
    Massage Intake Form
    Mayan Abdominal Therapy Initial Intake Forms — ***Please note that you must fill out forms and email to siennatraditional@gmail.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