Verification RequestPlease submit all fields below for insurance verification. Thank you! Treating Acupuncturist/Practice Name * Patient Name * (As listed with Insurer) First Name Last Name Patient Date of Birth * MM DD YYYY Patient Phone Number * (###) ### #### Patient Email * Primary Insurance * Your Employer Insurance Phone Number * (###) ### #### Member ID # * Are you the primary subscriber? * Yes No Diagnosis/Chief Complaint * Optional: To provide you with the fastest verification, you can send a photo of your insurance card to verifications@shaferbilling.com. Thank you!
