Insurance Verification

For your convenience, Affinity Acupuncture can verify your insurance benefits before you arrive. Please complete this online form and we will contact you as soon as the benefits are established.

Patient Information

Employer

Name *

First

Last

Middle Initial

Date Of Birth *

Gender *

Preferred method of contact *

Phone Number *

Email *

Address *

Address Line 1

City

State

Zip Code

Location Preference

Brentwood
Green Hills

Chief Complaint or Primary Diagnosis

Insurance Information

Insurance Company Name *

Insurance Company Phone Number *

Policy Number / ID Number *

Relationship to Insured *

Group Number

Claim Number if an accident

Date of accident or injury

Upload File (scanned insurance card)

Click or drag a file to this area to upload.

Additional Info

Comments