INSURANCE

To find out if insurance can help pay for your sessions, please follow these steps:

Fill out the Insurance Verification Form below.
Email the front & back of your insurance card and driver’s license to insurance@licacuwell.com.

Insurance VerificatioN FOrm

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Sex

M

F

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Interested in

Acupuncture

Physical Therapy

PRIMARY INSURANCE

Primary Insurance Company Name

Insurance Company Phone #

(###)

###

####

Insurance ID #

Group #

SECONDARY INSURANCE

Secondary Insurance Company Name

Insurance Company Phone #

Insurance ID #

Insurance verification normally takes a few days but it may take longer at this time. To check on the progress of your insurance verification, email us at insurance@licacuwell.com. Thank you for your patience.

Please be aware that all payments are due at the time of service until we have verified your insurance. We are currently not working with Cigna or Emblem Health.