Insurance Agreement Form

Insurance Checklist

Please read each item on this sheet carefully and ask your practitioner if anything is not clear.

If my insurance indicates that I have a co-pay, I understand that co-pays are to be paid on the day of treatment.*

Your Initials
I understand that it can take up to a month to determine for certain whether or not my insurance will cover acupuncture treatments.

Your Initials
I understand that if my insurance fails to pay for my treatments, I will purchase either individual acupuncture appointments or an acupuncture package at current Women in Wellness rates to cover the cost of my treatments.

Your Initials
I understand that if my insurance company pays me directly, I will pay Women in Wellness the amount that I received from my insurance.

Your Initials
I understand that if my insurance Explanation of Benefits (EOB) indicates that there is a Patient Responsible Portion due for my appointments, then my credit card on file will be charged for that amount upon Women in Wellness’ receipt of the EOB.

Your Initials
I understand that missed appointments and non-emergency cancellations within 24 hours of my appointment time will be billed at the current rate for individual acupuncture appointments (currently $85). I will call my practitioner if an emergency situation requires me to cancel my appointment within 24 hours. Cancellations more than 24 hours in advance will not be billed.

Your Initials
I agree to keep valid credit card information stored in my online account, and understand that missed appointments (as described above), co-pays, and Patient Responsible payments will be charged to that card. Women in Wellness will provide at least 24 hours' notice before charging my card.

Your Initials
I understand that my practitioner typically recommends coming in for treatment two or three times per week as I am just beginning treatment. This may be different than what my insurance covers. I have discussed this with my practitioner and we have agreed upon a treatment schedule.

Your Initials

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Insurance Agreement

Insurance Checklist

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