• Insurance Form

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  • 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.

     

  • Primary Insurance

     
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    Cancel of
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    Cancel of
  • Secondary Insurance

     
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    Cancel of
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    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.

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