PrimeLife Acupuncture: Check Your Insurance

First Name

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Last Name

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Phone Number

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Email Address

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Zip Code (Current address ZIP Code)

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Date of Birth

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Please describe the reason for your visit to our clinic.

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Insurance Carrier

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Your policy provider (Aetna, CareFirst, BlueCrossBlueShield, Anthem, Department of Veterans Affairs, United Healthcare)

Insurance Carrier Phone Number for Providers

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This information is typically located on the back of your insurance card.

Group Number

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Member ID Number

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Are you the primary policyholder on the insurance?

Yes

Let us know if you are the primary policyholder.

Primary Policyholder’s Name

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Patient Relationship to Primary Policyholder

How did you hear about us?

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Check Your Insurance Benefits

Please fill out the form below, and our team will promptly conduct a benefits check. Please allow 7-14 business days for a thorough response.

Thank you! Your submission has been received!

PrimeLife Acupuncture

What We Treat

Services

New Patient

Let us be a part of your Prime Life

Thank you!

Check Your Insurance Benefits

Please fill out the form below, and our team will promptly conduct a benefits check. Please allow 7-14 business days for a thorough response.

Thank you! Your submission has been received!

PrimeLife Acupuncture

What We Treat

Services

New Patient