Verify Your Insurance Benefits for Acupuncture & Integrative Care

Name *

First Name

Last Name

Date of Birth *

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DD

YYYY

Mobile Phone Number *

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Private Pay Non-Insurance Service(s) you're seeking: *

Select all that apply

Dry Needling / Myofascial Trigger Point

Pelvic Floor Acupuncture & Dry Needling

Myofascial Cupping Therapy

Medical Therapeutic Massage

Facial Cosmetic Acupuncture

Facial Microneedling

Full-Body Red Light Therapy

Traditional Chinese Herbs

InBody Composition Scan

Insurance-Covered Service(s) you're seeking: *

Select all that apply

Traditional Acupuncture

Electro-Acupuncture (E-Stim)

Myofascial Cupping Therapy (Depends on Insurance)

Which In-Network Acupuncture Provider(s) would you like to see? *

(read below for bios, network status, & specialty)

Dr. Aaron Lee (Licensed Acupuncturist He/Him) English

Dr. Eric Sun (Licensed Acupuncturist He/Him) English, 普通话流利

Dr. Gahwi You (Licensed Acupuncturist She/Her) English, 한국어에 능통하다

Dr. Charlie Hsu (Licensed Acupuncturist He/Him) English, 普通话流利

Dr. Jackie Chan (Licensed Acupuncturist She/Her) English, 普通话流利

Dr. Supreeth Shivakanth (Licensed Acupuncturist, He/Him) English, Hindi

Which Out-of-Network Provider(s) would you like to see?

(read below for bios, network status, & specialty)

Kirsten Cooper (Licensed Acupuncturist, Tui-Na Specialist, She/Her) English

Which Massage Therapy Provider(s) would you like to see? (read below for bios, network status, & specialty)

(read below for bios, network status, & specialty)

Justin Ewaska (Massage Therapist, He/Him) English

Preferred days/times *

Choose the best block and day that work for your schedule

Weekdays (Morning/Afternoon/Early Evening)

Weekends (Sat/Sun)

Insurance Benefits Disclaimer: Most benefits require that the chief complaint be a "covered condition" under the health plan's medical policy bulletin for acupuncture. Covered conditions are 99% related to musculoskeletal conditions like neck and low back pain, shoulder pain, arthritis, etc. and very rarely cover Fertility Treatments, Pelvic Floor Disorders, Relaxation and Mental Health Disorders. Do you understand that if your chief complaint is not billable or covered, that you may need to pay out of pocket for a treatment. We will be more than happy to provide you a superbill if this is the case. *

Yes

No

Massage Therapy is not a covered insurance benefit by ANY health plan, other than Worker's Compensation and Auto Injury. Do you understand that in order to book a massage, you will need to pay out of pocket for your service? If yes, please call in for pricing and full deposit for treatment. *

Yes

No

Verification of benefits are not a guarantee of payment or coverage, all coverage and benefit limits will be determined once the insurance claim is paid out. Do you understand that by using your insurance benefits, there is a risk that you may need to pay out of pocket for your entire treatment? *

Insurance coverage is a confusing and complex field, the statement listed above is the standard statement that insurance tells us as providers, we are only passing this statement along to you.

Yes

No

Quick Office Policy Rundown: Credit Card on file is required at the time of booking. If you do not have a valid credit card, we will still book you in, but if you miss your first appointment (unless due to emergency) you will no longer be allowed to be seen at our clinic. Late cancellations are less than 24 hours and late reschedules are 12 hours or less, your first late cancellation/reschedule will be a warning, but future ones will incur a $100 fee. Do you understand? *

Yes

No