FEES and INSURANCE

FEES

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. 

 

 

INSURANCE ASSIGNMENT

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 financial 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

JEFFREY S. WERNICK, Lic.Ac.

197 TURNPIKE STREET  

CANTON, MA. 02021-2309

781 - 828-6636