Name (as shown on insurance card) *
Name (as shown on insurance card)
Date of Birth
Date of Birth
Please include City, State and Zip Code
Subscriber's name, date of birth, street address (city/state/zip), phone number

I am in network with BlueCross & Cigna and bill out of network with Aetna and United Health Care. Acupuncture benefits are not guaranteed. To find out if you are covered and your specific benefits please fill out the form below. We will get back to you within 72 business hours. Please note, if you are not the subscriber on the policy you will need to include their information at the bottom of the form.  

Patient Information