Instructions: Call the member services number on the back of your card.  Speak with an agent and ask them all of the questions below.  Please fill in the answers to the questions and bring this sheet with you to your next visit.

Date: ________ Patient Name: ________________________ DOB: _________________
Name of Health Plan: ____________________ Member ID#: ______________________ Group#:________________
Primary Policy Holder Name:_____________DOB:________
Call Reference #: _______________________
Provider Line Phone Number: ________________________________
Do I have Acupuncture benefits? YES____ NO____
Is my acupuncturist In Network? YES____ NO____
Do I have out of network coverage? YES____ NO____
Is a physician referral necessary? YES____ NO____
Is a prior authorization necessary? YES____ NO____
Is my coverage subject to deductible? YES____ NO____
Has my deductible been met? YES____ NO____
Deductible amount: _____________How much of my deductible has been met?_________
Co-Pay amount: ______________  Co-Insurance amount:____________
Number of acupuncture visits allowed per year: ____________
Maximum dollar amount paid per year for acupuncture:________________
When does my plan year begin or renew? _____________
Claims address: _____________________________________________ ______________________________________________________________
Payer ID # for electronic billing: ________________________________