Insurance Benefit Verification Form — Bright Shen Acupuncture

We accept Blue Cross Blue Shield, United Healthcare and Multiplan PPO.

Our staff will check your benefits before treatment at no cost to you.
Please call our office if you have questions at (847) 648-7990.

Please complete this form and we will begin the process and we will call you to discuss your acupuncture benefits.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

Insurance Company

Member ID Number

Group Number

Are you the primary insurance holder?

Yes

No

Customer Service phone number off the back of the card

(###)

###

####