Insurance | Advanced Healthcare Clinic

First Name:*

Last Name:*

Gender:*

E-mail:*

Address:*

City:*

State:*

Zip:*

Phone:*

Referred By:

Insurance Co:*

Insurance Co. Ph:*

Employer:*

Insured ID #:*

Group #:*

Insured Name & ID# (if different from patient):

Relationship to insured:*

Insured DOB:

Day :*

Month :*

Year :*

Insurance Type:*

Claim # if an accident:

Date of Accident / injury:

Condition or illness you are seeking treatment for:*

By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to Dr. Dube, his staff and to a third-party biller. I understand that I have the right to request any and all restrictions to the use of disclosure of my health information.

* Required

Let us check and see if your insurance covers acupuncture.

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