INSURANCE VERIFICATION CHECKLIST 

Instructions:  Call the member services number on the back of your card.  Speak with an agent and ask them all of the questions below. 

Do I have Acupuncture benefits?       ❏ YES       ❏ NO  

Is my acupuncturist In Network?       ❏ YES      ❏ NO

Do I have out of network coverage?       ❏ YES      ❏ NO

Is a physician referral necessary?       ❏ YES      ❏ NO

Is a prior authorization necessary?       ❏ YES      ❏ NO

Is my coverage subject to deductible?       ❏  YES      ❏ NO

Deductible amount: _____________

Has my deductible been met?       ❏ YES      ❏ NO 

How much of my deductible has been met?_________

Co-Pay amount: ______________

Co-Insurance amount:______________ 

Number of acupuncture visits allowed per year: ____________

When does my plan year begin or renew? _____________ 

Do I have a second insurance plan requiring coordination of benefits?   ❏ YES  ❏ NO