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Note: Superbills are in this Insurance Forms Packet, not in the Big Forms Packet We can customize these forms for an additional charge–name, address, phone, license number, provider number, change of coding, etc. Custom order form is contained within the packet.

Packet #2 Insurance Forms Packet $29.50 When ordering, please specify if you are in a combined professional practice, ie. chiropractic/ acupuncturist, physician/acupuncturist, acupuncturist/therapeutic massage practice. Includes: high quality master forms you may use to photocopy for your personal practice use. New Patient Preparation Packet for Insurance Billing. Welcome Brochure & Office Policy Patient Registration (Pt. Insurance Information) New Patient Information on Insurance Insurance Questions and Answers for Patients How to Submit Your Insurance Claim Verification of Insurance Coverage for Acupuncture 3 Information on obtaining Coverage 3 Authorizations for General Insurance Coverage 5 Insurance Billing and Accounting Forms 6 Financial Agreement Re: Insurance Payment 3 Insurance Tracking Forms 5 Auto, Personal Injury, Work Injury Forms 5 Reports for Insurance 8 Workers' Compensation Forms See TABLE OF CONTENTS.

TABLE OF CONTENTS FOR THE INSURANCE FORMS PACKET

Includes: Roster and Basic Instructions Re: Insurance Forms Patient Preparation for Insurance Billing Welcome Brochure & Office Policy Patient Registration New Patient Information on Insurance Insurance Questions and Answers for Patients How to Submit Your Insurance Claim Verification of Coverage for Acupuncture Care Insurance Coverage for Acupuncture Re: Obtaining Coverage Coverage of Acupuncture by Licensed Acupuncturists Coverage of Acupuncture Letter to Individuals & Companies Petition for Acupuncture Coverage Authorizations for General Insurance Coverage Authorization to Release Medical Information Physician Referral for Acupuncture Pre-authorization to Treat Insurance Billing and Accounting Forms One visit Superbill 5 Visit Superbill Universal Claim Form Insurance Control Form for Recording billing, payments, & tracking Sample Ledger Card Financial Agreement Re: Insurance Payment Notice of Liability to Insurance Co. and Patient's Attorney Irrevocable Assignment of Benefits Power of Attorney to Endorse Checks to the Office/ Practitioner 60 Days Extension of Credit in Consideration of Assignment Deductible Coverage Policy for Patients 60 Days `Payment Letter to Patient

Further Insurance Tracking Duplicate Superbill. Advise status. Insurance Tracer Take Action Letter Auto, Personal Injury, Work Injury Agreements Automobile/Work Injury Policy Statement Personal Injury Financial Policy Pre-authorization for Treatment by Ins. Co. Re: Medical Reports and Acupuncturist's Lien Statement of Report Charges (and agreement of coverage by patient insurance companies, and/or attorney) Reports for Insurance Patient Fill-In Progress Report (Patient Evidence) Treatment Summary Report Initial Report Interim and Final Report Complete Narrative Report Workers' Compensation Workers' Compensation Worksheet Workers' Compensation Questionnaire Letter of Authorization to Employer for Workers' Compensation Notice and Request for Allowance of Lien Workers' Compensation Doctor's First Report of Injury - Workers' Compensation Monthly (and Final) Billing Form Application for Adjudication of Claim Declaration of Readiness to Proceed Managed Care Provider Application

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