Home Page About Us Stop Smoking Program Directions Parking Fees and Insurance Preparing For Your First Appointment


All fees are paid at the time of the visit.  Cash or check are accepted.  Checks are payable to "Jeffrey Wernick". If you have Health Insurance or Flexible Spending Plan, the office will be happy to assist you in obtaining reimbursement. Many insurance policies do cover acupuncture but this office makes no representation that yours does. As your insurance is a contract between you and the insurance company, this office is not responsible for your coverage or benefits. 




Where appropriate, this office can arrange to accept payment directly from your insurance company. You must provide all insurance information to this office and your coverage must be confirmed. At the time of each service, you must pay any fees, deductibles, and co-payments not covered by your insurance.

Any assigned payments mistakenly sent to you or remaining balances not paid by the insurance must be paid to this office within 30 days. Past due balances may have an interest charge of 1.5% applied per month.

Please contact your Insurance company to verify coverage for Acupuncture. Print out the form below.  Ask the following questions and fill in the information as completely as possible. Send this form back in to the office or bring it with you on your first appointment. 


Date Called: ___________



Patient Name: _____________________   


DOB: _____________________

Address: ________________________     

Phone: _______________


Name Of Insurance Company:___________________________________

Phone No.: ____________________     Policy No: ___________________

Contact Person: ___________________     Group No.: ________________


Name Of  Insured Policyholder:  _____________________________ 


DOB: _________


Policy No. (if Different): _______________________________________


Address Of Policyholder: _______________________________________

Employer: _________________________________________________

Type:     Health: ___   Worker's Comp: ___  Personal Injury: ____

              Other (Specify): ________________________________________


1. Does My Policy Cover Outpatient Acupuncture by a Mass. Licensed Acupuncturist ?      


                                                       Yes:_____    No: ______       If No, Stop Here. 


For My Medical Conditions?   Yes:_____    No: ______       If No, Stop Here. 



List All Your Medical Conditions: _________________________________







If your insurance does not cover acupuncture, contact the Acupuncture Center of Canton to make other finacial arrangements.



                                  If Yes, Ask The Following Questions.


2. What Is The Effective Date Of My Policy? _______________________

     What Is The Calendar Year Of My Policy? _______________________



 3. In Network Acupuncture Benefits and Limits: _____________________



 Out of Network Acupuncture Benefits and Limits:






    Is Jeffrey Wernick, Lic. Ac, in my provider network?    Yes:____   No: ____



What Diagnostic Codes or Requirements Are My Benefits Limited To?







     Maximum No. Of Visits and Payment Allowed Per Year For:


      Acupuncture Treatments: ________________________________


       Exams: ____________________________________________


       Herbs and Remedies: __________________________________


       Physical Medicine: ____________________________________



4. What Is The Deductible? __________________________________ 


     When Did It Begin? ________   For What Period Of Time? ___________


     How Much Has Been Paid So Far? _____________



5. What Percentage or Amount Of My Bills Are Covered? _______________


   What Is My Co-Pay? _______________________________________



6. Maximum Yearly Amount Allowed? ________________________


Maximum Number of Visits?       ____________________________


How Much Is Left?         __________________________________



7. Can Benefits Be Assigned To The Acupuncturist?   Yes:_____    No: ______      




8.  Where Should Claims Be Sent?



      Name:    ________________________________________


      Address:  _______________________________________




      Claims Telephone No.: ______________________________


      Claims Fax No.: ___________________________________          




9. Is Any Further Prior Approval, Referral, Reports or Authorization Necessary?


      Yes: _____  No: _____


      If Yes, What Is Required? _____________________________________



Where Should It Be Sent?


Name: ___________________________________________________


Address: __________________________________________________


Phone: ____________________    Fax: __________________________




10. List Any Other Special Forms, Information or Procedures Needed To Be Submitted:






 11. Reference number for this call:     __________________________________




Acupuncture Center of Canton



CANTON, MA. 02021-2309

781 - 828-6636