FEES and INSURANCE
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: _____________________
Name Of Insurance Company:___________________________________
Phone No.: ____________________ Policy No: ___________________
Contact Person: ___________________ Group No.: ________________
Name Of Insured Policyholder: _____________________________
Policy No. (if Different): _______________________________________
Address Of Policyholder: _______________________________________
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: ________________________________
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?
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?
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