8/3/2019 Medical Benefits Request Form

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Medical Benefits the Los Angeles Mobile Acupuncture group Page 1Verification Request

PO Box 352116, Los Angeles, CA 90035-1515 P: (866) 629-8089 F: (866) 629-8089 www.lamobileacu.com version 1-18-2012

PATIENT INFORMATION

First Name:________________ Middle Initial_____Last Name:________________________________

Address:__________________________________City:______________________________________State:_________________ Zip:________________E-mail:_________________@_________________Twitter:@__________________________________Facebook.com/_____________________________Google+__________________________________

Sex: M F Age:_______________Birth Date:________________________________Married Widowed Single Minor

Separated Divorced Partner for___years

Occupation:_______________________________Employer/School:__________________________

Address:____________________________________________________

State:__________ Zip:_______________Phone: ( ) _________ -_________# of hours per week:_________________

Spouse:__________________________________Date of Birth:__________ SSN:_____-_____-_____Employer:_________________________________

Whom may we thank for referring you?__________________________________________________

PHONE NUMBERSHome: (_______)__________-________________Cell: (_______)__________-________________Work: (_______)__________-________________Best time and place to reach you:______________

_________________________________________

EMERGENCY CONTACT

Name:____________________________________Relationship:__________________________Cell #: (_____) ______ - ________________Home: (_____) ______ - ________________Work: (_____) ______ - _________________

INSURANCE INFORMATION

Who is responsible for this account?___________________________________________________________Relationship to Patient:__________________________

Date of Birth:__________ SSN:_____-_____-_______Insurance Co:_________________________________Group #:_____________________________________Phone #:(_______)_________ - _________________

Is patient covered by any additional insurance?Y NSubscribers Name:____________________________Date of Birth:__________ SSN:_____-_____-_______Relationship to patient:__________________________Secondary Insurance Co:________________________Group #:_____________________________________

Phone #:(______)________ - ____________________

Assignment and Release of Benefits

I certify that I, and/or my dependant(s), have insurancecoverage with:________________________________and assign directly to the Los Angeles MobileAcupuncture group, assigned provider or agents allinsurance benefits, if any, otherwise payable to me for

services rendered. I understand that I am financiallyresponsible for all charges whether or not paid by myinsurance submissions.

Los Angeles Mobile Acupuncture and its providers mayuse my health care information and may disclose suchinformation to the above named insurancecompany(ies) and their agents for the purpose ofobtaining payment for services and determininginsurance benefits or the benefits payable for relatedservices. This consent will end upon written notice or 7years after last visit.

Patient Signature (Or Patient Representative) Date(Indicate relationship if signing for patient)