Halcyon Acupuncture of Long Island PLLC
Insurance Verification Form
Insurance Verification
Contact Me By
Email
Phone Call
Contact Number
Patient Information
Employer's Name
First Name
MI
Last Name
Social Security Number
( Last 4 digits )
Date of Birth
Sex
Male
Female
Others
Preferred Method of Contact
Phone
Email
Patient's Phone Number
Patient's Email
Chief Complaint / Primary Diagnosis
Address Line 1
Address Line 2
City
State
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AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Insurance Information
Insurance Company Name
Payer
N/A
Phone
Policy ID / Member ID
Relationship to Insured
Self
Spouse
Child
Others
Group #
Policy Holder First Name
PH MI
Policy Holder Last Name
Policy Holder Sex
Male
Female
Others
Policy Holder DOB
Subscriber # / ID #
Claim # if an Accident
Date of Accident / Injury
Additional Information
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Contact Me By
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Employer's Name
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Patient Name
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SSN
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Date of Birth
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Sex
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Preferred Method of Contact
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Patient's Phone Number / Email
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Primary Diagnosis
-
Address
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Insurance Company Name
-
Insurance Phone
-
Payer ID
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Policy ID / Member ID
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Relationship to Insured
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Policy Holder Name
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Group #
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Claim # if an Accident
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Date of Accident / Injury
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