Acupuncture Allentown Insurance Form

Insurance Information

We accept many insurance plans that cover acupuncture and complimentary
alternative medicine, including all Auto Insurance. Just fill in the form below
and we will be happy to verify your benefits and call you back.
* Required

* First Name:

* Last Name:

* E-mail:

* Address:

* City:

* State:

* Zip:

* Phone:

* Referred By:

* Insurance Co:

* Insurance Co. Ph:

* Employer:

* Insured ID#:

* Insured DOB:

Year:

* Insured SS#:

* Insurance Type:

HMO PPO EPO POS
Auto Insurance Workers’ Comp.

* Condition or illness you are seeking treatment for:

By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to Warren Miles, his staff and to a third-party biller. I understand that I have the right to request any and all restrictions to the use of disclosure of my health information.