[Home] [Back] www.healingartscenter.com
 

Insurance Inquiry Form

It would be helpful to call your insurance company prior to your appointment for the following information. You may email the information by using the form below or print and fax it to us.
The document is available in PDF format.
Fax to  (509) 685-0358
 

 
[Insurance Inquiry Form in PDF format here]

 
 
  Patient Name :
  Subscriber Name :
  Subscriber Date of Birth :   example: 03/24/74
  Subscriber Social Security Number :
  Employer of Subscriber:
  Insurance Group # :
  Insurance Company :
  Phone Number : include area code
  Contact Person :
  Date :
  Time :
  Benefit Year :
  Deductible :
  Met? :
  Contract Limit out of pocket :
  Co-Pay :
  Deductible :
  Preauthorization Required :
  Referral Required :
  Who is eligible to provide services? :
  ( M.D.; D.O.; Ph.D.; Acupuncturist; Mental Health Counselor )
( MSW: Licensed, Certified, Registered, Masters  )
  Do you have mental health benefits? :
  Do you have physical therapy benefits? :
  Massage :
  Biofeedback (90901) :
  Alternative Health Care Benefits :
(Naturopathic)  
  Secondary Insurance Company? :
  Phone # :
  Policy number :
  Subscriber_Name :
  Additional Comments:
 
 
    [Home] [Back] www.healingartscenter.com