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

As listed on insurance. For insurance verification purposes only.

M

F

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 #

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.

Payments are due at time of service until we have verified your insurance.

We are currently not taking Cigna or Emblem Health.