Free Insurance Benefits Check

Please fill out the following form so that we may check your insurance benefits.  

Note:  Medicare and Medicaid do not cover Acupuncture treatment at this time.  

The information on this form is secure and confidential.  

Twelve Rivers Acupuncture will not share your information with 3rd parties without your consent.


Patient's Name *
Patient's Name
Preferred Method of Contact *
Are you the Primary Insurance Holder? *
(For example, NJ Direct, PPO, EPO, HMO, POS, etc)
Please include all letters and numbers
May be found on the back of your insurance card
Please list up to three reasons for seeking acupuncture treatment