Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient's name in the designated field. This is the name of the individual receiving acupuncture or oriental medicine services.
3. Enter the patient's Social Security number in the specified section. Ensure accuracy to avoid any verification issues.
4. Fill in the health insurance details, including insured person's name, Social Security number, name of insurance provider, and their contact information.
5. Specify the billing address for the insurance company, including city, state, and zip code.
6. Input the policy number, group number, effective date, and employment information of the insured.
7. Indicate for acupuncture if the service is covered (Yes/No) and note the deductible amount. Check if the deductible has been met.
8. Fill in limits for coverage, such as maximum allowable amount, amount per visit, and number of visits. Note any exclusions if applicable.
9. Complete sections for vitamins, herbs, supports/braces, and orthotics as necessary.
10. Document the contact person and date of the conversation regarding benefits or coverage.
11. If applicable, complete the auto insurance section, providing similar information as listed in the health insurance section.
12. Fill out the worker's compensation section, including the name of the insurance provider, contact details, and claim information.
13. Confirm if written authorization is given and who referred the patient. Include the name of the individual verifying the information.
14. Finally, review all fields to ensure accuracy before saving, downloading, printing, or sharing the completed form.

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