Insurance Information

We accept many insurance plans that cover acupuncture and complimentary
alternative medicine, including all Auto Insurance. Just fill in the form below
and we will be happy to verify your benefits and call you back.
* Required

* First Name: * Last Name: * E-mail: * Address: * City: * State: * Zip: * Phone: * Referred By: * Insurance Co: * Insurance Co. Ph: * Employer: * Insured ID#: * Insured DOB: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: * Insured SS#: * Insurance Type: HMO    PPO    EPO    POS Auto Insurance   Workers’ Comp. * Condition or illness you are seeking treatment for: By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to the staff of Harmony Wellness Center and to a third-party biller. I understand that I have the right to request any and all restrictions to the use of disclosure of my health information.