Center for Health & Wellness
a division of Highland Medical Group, Inc.

Rodney Dunetz, A.P., D.O.M.

Insurance Verification Form

Many insurance companies are providing coverage for acupuncture and some of the other therapies and treatments we use. Our Insurance Manager will gladly verify your insurance coverage after you complete and submit the short form below.

Please fill in all information. Missing or incomplete information will delay your request. Thank You.

Full Name: Last Name, First Name

Address 1:

Address 2:

City: State: Zip:

Home Phone: Cell Phone:

Email:

Your DOB: Month,Day,Year

SEX

Patient,Subscriber# / ID:

Group #:

Insurance Type:

Insured Name & ID#(if different from Patient):

Relationship to insured:

Marital Status:

Insurance Company Name:

Ins. Co. Phone #:

Claim # if accident:

Date of Accident/Injury:

Condition or illness you are seeking treatment for:

Referred By:

Other Information:

By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to the staff at Center for Health & Wellness (a division of Highland Medical Group, Inc) 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.