New Patient Form

PATIENT INFORMATION
First Name:
Middle Inital:
Last Name:
Age:
Home Address (street, city, state, zip):
Phone 1:
Type:
Phone 2:
Type:
Phone 3:
Type:
Phone number where we can leave you a message:
What is your preference for automated appointment reminders?
Email:
Employer:
Work Address (street, city, state, zip):
Weight:
Height:
Gender:
Name you go by:
Date of Birth:
Marital Status:
Emergency Contact:
Relationship:
Emergency Contact Phone:
Who referred you / how did you hear about MA&W?
INSURANCE INFORMATION

The insurance/billing information questions are necessary. Please provide your insurance ID card for photocopying.

I understand that if I am not paying for treatment at the time of service, I need to supply Meridian Acupuncture & Wellness with my Social Security Number.

Insurance Company:
Phone:
Insured's ID #:
Group #:
Birth Date:

As a service to our patients, Meridian Acupuncture & Wellness will submit the charges for medical treatment to the patient's insurance company. However, the patient is primarily responsible for paying any and all medical expenses incurred at this office. We may attempt to verify, in advance, that the patient's insurance company will pay for specific medical procedures. Occasionally, even though coverage was verified before the medical services were provided, the insurance company denies the claim. If the insurance company denies payment or will not pay a portion of the medical bill, the patient is responsible for payment of account balance. Likewise, if the patient has not met his/her deductible under a given insurance plan, the patient will be responsible for the amount of the deductible, in addition to whatever the insurance does not pay.

Although we will verify insurance coverage for our records, we strongly encourage our patients to call their insurance company to verify their coverage prior to their first appointment.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Meridian Acupuncture & Wellness. I also authorize my insurance company to release any information required to process claims. I agree to be responsible for payment of service in the event my insurance company does not agree to pay for these services. (Not signing this document does not release you from responsibility of payment.)

Patient’s or Authorized Person’s Signature:
Date:
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