If you would like us to verify if your insurance policy will cover acupuncture, please contact our office with the following information or you can call or fax our office.

Patient name

Patient Contact Number (Home, Work or Cell)

Patient DOB (mm/dd/yyyy)

Patient's Reason for Treatment

Primary Card Holder's Name

Primary Card Holder's DOB (mm/dd/yyyy)

Insurance Company

Insurance ID#

Insurance Group#

Insurance Type of Plan (HMO/PPO/POS/Others)

Insurance Company Phone Number

Employer

Patients with Insurance

As a courtesy, we will accept your insurance assignment as soon as this office verifies your coverage. We will file your claim for you as soon as you supply this office with all required information as dictated by the parameters of your insurance coverage. YOU must make all arrangements for policy requirements.

Please remember that regardless of any statements by your insurance company, YOU are ultimately responsible for any and all fees for services rendered at this office. It is standard practice for insurance claims to be paid or denied within 30 days of submission. If your insurance company has not paid within 60 days, YOU ARE THEN RESPONSIBLE FOR ANY BALANCE ON YOUR ACCOUNT.

If this office accepts your insurance assignment, you will be required to sign an "Authorization to Pay" form and any other assignment of lien forms required by your insurance company on your first visit. This office will NOT enter into a dispute with your insurance company over your claim. THIS IS SOLELY YOUR RESPONSIBILITY AND OBLIGATION.

Worker's Compensation

YOU must make all arrangements for your worker's compensation benefits PRIOR to beginning treatments at this office. This office cannot be your treating physician of record under Texas Worker's Compensation Guidelines. YOU must make arrangements, for a referral for acupuncture treatments from your treating physician, and have the approval of your adjuster for that referral. We must have a copy of each of these items in your file.

Auto Accident Victims

We will file claims to any responsible insurance company for your treatment of injuries as a result of an auto accident. YOU will need to make the necessary arrangements that allow us to file those claims. Cases will be reviewed and accepted on an individual basis.

YOU must have written verification for your acupuncture treatment from the responsible insurance adjuster acknowledging acupuncture treatment and payment prior to beginning your treatment. YOU must supply this office with ALL information necessary to file an accurate claims.

Group/Individual

This office must adhere to the boundaries of your particular insurance policy. If your policy requires a deductible, you will be responsible for treatment fees at the time services are rendered until the time your deductible is satisfied. The billed fee may or may not be applied to your deductible - ONLY YOUR INSURANCE CARRIER determines that. YOU are responsible for any and all copays or coinsurance payments at the time services are rendered. If your policy requires a referral of any kind, YOU must arrange that referral BEFORE beginning treatment at this office.

We are required by law to record every aspect of your particular treatment. This results in breaking down your treatments into CPT codes as previously defined. Every insurance company processes claims differently. When you receive an EOB (Explanation of Benefits) detailing filed claims, the breakdown may or may not be as we submitted it. THIS OFFICE HAS NO CONTROL OVER THE PROCESSING OF CLAIMS BY ANY INSURANCE COMPANY. We submit claims the same regardless of the insurance carrier.

This office also has no control over the usual and prevailing or reasonable and customary charges as defined by any given insurance company processing CLERK at any given time. Legally there is no such thing as usual and prevailing, but insurance companies have agreed to a unified concept of this “average charge for a medical service or treatment”.  Companies often do not agree on an exact or consistent average.

All payments received from your insurance carrier will be credited to your account in a timely manner. If there is an overpayment, you will know by your EOB and we will send you a refund if your account is paid in full.

AGAIN, YOU ARE ULTIMATELY RESPONSIBLE FOR ALL FEES DUE THIS OFFICE FOR SERVICES RENDERED. THIS OFFICE WILL NOT ENTER INTO DISPUTE WITH YOUR CARRIER OVER ANY CLAIM. IT IS YOUR RESPONSIBILITY AND OBLIGATION TO MAKE SURE THIS OFFICE IS PAID.

Patient with Insurance

All fees are based on the AMA fee guidelines. We are required to break down every aspect of your treatment into as many different CPT codes as applicable. Charges may consist of all or any multiple of the following: (Please keep in mind that although these are the charges submitted to the insurance company, each insurance company will apply the contracted fee accordingly.  The patient is not responsible for the difference between the amount charged by the health care professional and the amount allowed by the contract.  However, the patient is responsible for any deductible, coinsurance amounts and amounts over the annual benefit limits for this service, up to the eligible expense.)