Forms > Office Forms

• Form 1 - New Patient Intake Form​ 
• Form 2 - Patient Systems Survey     
• Form 3 - Health Insurance Verification Form
• Form 4 - Personal Info Update Form
• Form 5 - New Work Comp Patient - Case Info

1. Please identify the forms you need to fill out from the information provided below
2. Print and Hand write - Please print them  and  fill out as best you can prior to coming to your appointment.  NOTE: When printing from mobile devices, sometimes the google docs seem to result in poor formatting. Please try to make sure the document prints with relatively correct formatting. If you can't get a  formatted document to print, please come to your appointment 20 minutes early and fill out a document in our office. ​
3. GDoc or PDF  - To get a digital copy use  File > Make a Copy (for a google doc)  or File > Download As (for a pdf). The PDF will not be fillable. It will be a static document. NOTE: Do not select "File > Share" . That is for sharing as if we wanted to allow you to edit our documents. 
4. Health Insurance - If you would like to use your Health Insurance for Acupuncture,  you will need to verify benefits with your provider prior to scheduling your appointment with me.  Form 3 makes this process easy. 
5. Completed Intake Forms - Please bring your filled out forms (and insurance card if applicable) with you to your appointment.    ​If you can not fill out the forms prior to your appointment,  PLEASE arrive 30 minutes early to fill those out so we can remain on schedule.

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Office Forms for NEW PATIENTS and EXISTING PATIENTS

NEW PATIENTS not using Health Insurance
This is for new Acupuncture and/or Clinical Nutrition Patients who will be paying with cash, credit card or check.  

•  Form 1 - Patient Intake Form
• ​ Form 2 - Patient Systems Survey
• If you are coming for clinical nutrition, please also see the "Clinical Nutrition - Visits 1 through 4 - Expectations Form" on the Forms menu as well.

EXISTING PATIENTS
Existing Patients who are returning with unknown new issues 

• ​ Form 2 - Patient Systems Survey

Existing Patients whose Health Insurance has changed 

• ​ Form 3 - Health Insurance Verification Form

Existing Patients whose contact info has changed

• Form 4 - Personal Info Update Form

NEW WORK COMP PATIENTS
This is for new Acupuncture Patients coming for Work Comp

•  Form 1 - Patient Intake Form
• ​ Form 2 - Patient Systems Survey
• Form 5 - New Work Comp Patient - Case Info
  

NEW PATIENTS wanting Health Insurance coverage / reimbursement for Acupuncture Services.  

•  Form 1 - Patient Intake Form
• ​ Form 2 - Patient Systems Survey
• ​ Form 3 - Health Insurance Verification Form

As indicated below all new insurance patients (in network and out of network) will be expected to make payment in full at time of service with credit card, check or cash. ​

General Comments about Insurance...

• Acupuncture and Private Health Insurance -- Health Insurance may or may not cover Acupuncture depending on your plan.  Most plans cover it to some degree for both in-network and out of network providers.   We may or may not be an In-Network provider (we are not in network with very many companies any more).   We provide a script in our Health Insurance Verification form to determine our network status and  your Acupuncture benefits for both in network and out of network providers. 
• Acupuncture and Medicare -- Medicare does NOT cover Acupuncture at all, BUT if you have secondary insurance that covers Acupuncture,  you can use a "Super Bill" (a receipt for services from us designed for the insurance industry) to get a denial letter from Medicare, and then you can submit the denial letter and a copy of the Super Bill to your secondary carrier for credit/reimbursement.
• Clinical Nutrition, Private Health Insurance and Medicare -- Neither Health Insurance nor Medicare covers nutrition visits, nutrition products, or herbs.  
  
  ​For more/detailed educational information on all items relevant to insurance please see the Education>Health Insurance menu

Comments about payments for those with Insurance...

• All new insurance patients (both in-network and out-of-network) will be expected to pay for services in full at time of service.  New Patient Appointments are approximately $160 and subsequent visits are in the 60-85 range (see our pricing page for current pricing).
• In Network vs Out of Network Status - There is a script in our Insurance Verification Form below which will help you make a call to your insurance company to determine our network status as it pertains to your coverage, and it will also help you get a good understanding of your Acupuncture benefits  (Note,  we are not "in-network" with many providers these days. 
• In Network Benefits -- For those with insurance in which we are an "in network" provider,  we expect payment in full at time of service.  We will then file insurance claims for you, and any reimbursements we get for those services will be paid back to  you in the form of a check (since you already paid in full).  Once we have established a payment history with you and your insurance company, you will no longer be required to pay at time of service. 
• Out of Network Benefits -- For those with insurance in which we are an "out of network" provider,  we expect payment in full at time of service at all times.  We will provide you with a "Super Bill" after each visit and that is a special type of receipt that you can submit to your insurance company for appropriate deductible credit and/or cash reimbursement.