Insurance Verification Form


    * = Required

    Your Name*

    Your Email*

    Your Phone*

    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:

    Charlene Fauntroy
    Phone: 415-585-1990
    Hours: Mondays to Fridays 2:00 pm – 6:00 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 Clinic Network, San Francisco Network, or UCSF.  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!