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Let us check and see if your insurance covers acupuncture.

We accept many insurance plans that cover acupuncture and integrative medicine, including all Auto Insurance. Just fill in the form below and we will be happy to verify your benefits and call you back.

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


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