Insurance Form

Insurance Form
Patient Name (as it appears on insurance card) *

First Name Last Name
Patient Phone Number (if not already provided)

Area Code Phone Number
Patient Email (if not already provided)
example@example.com
Date of Birth *

Month Day Year
Date
Gender (according to your insurance company) *

Female Male
Workers Comp or Automobile Insurance

(If Applicable)
If your visit today is related to an accident and you wish to utilize Worker's Compensation or Automobile Insurance please fill out this section. If not, please skip this section.
Is this visit related to an accident?

Yes No
If so, please list date and place of accident
If so, was this accident related to work?

Yes No
Name of Insurance Carrier
Address of Insurance Carrier
Claim #
Name and Phone # of Insurance Adjustor
Attorney Name and Phone #
Primary Insurance
Insured's Name (if different from patient)

First Name Last Name
Insured's Date of Birth

Month Day Year
Date
Insured's Gender

Female Male
Relationship to Patient
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name/Address
Insurance Carrier Name/Address
Insurance Carrier Phone (from back of card)

Area Code Phone Number
Member ID #
Group #
Please attach a scan of the front of your insurance card

Browse Files

Cancel of
Please attach a scan of the back of your insurance card

Browse Files

Cancel of
Secondary Insurance
Insured's Name

First Name Last Name
Insured's Date of Birth

Month Day Year
Date
Insured's Gender

Female Male
Relationship to Patient
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name/Address
Insurance Carrier Name/Address
Insurance Carrier Phone Number (from back of card)

Area Code Phone Number
Member ID #
Group #
Please attach a scan of the front of your insurance card

Browse Files

Cancel of
Please attach a scan of the back of your insurance card

Browse Files

Cancel of
Assignment of Benefits and Release

I hereby authorize payment directly to Healthpointe Enterprises, Inc. (dba Healthpointe Acupuncture & Wellness) for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges if insurance does not cover them. I authorize Healthpointe Enterprises, Inc. to release any information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Submission to insurance companies is not a guarantee of payment. I also understand that the full fee will be charged if I miss an appointment giving less than 24 hours notice. I understand that this missed appointment fee will not be covered by insurance and that I will be responsible for payment.
Patient/Guardian Signature *

Clear
Please Print Patient/Guardian's Name
Today's Date

Month Day Year
Date
Should be Empty:

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