Insurance(Updated)

Welcome to Grace Acupuncture Clinic!

In these days, lots of patients asking us this kind of question, “Are you taking insurance?”

My answer is "YES". If you would like to use your health insurance, please provide the following information at least 24~48 hours prior to your appointment through submitting following form, or phone call at 281-671-7487:

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Insurance Verification Form

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Patient name: *

Gender: *

Full Address(Street, City, State, Zip): *

E-mail address: *

Date of birth(mm/dd/yyyy): *

Insurance carrier: *

Insurance ID number: *

Phone number for provider(front or back of card): *

Insured name(if different with patient): *

Insured person's date of birth(mm/dd/yyyy): *

Self

Child of insured person

Spouse of insured person

Other

Major Complaint(s): *

Captcha (spam protection code) *

I hereby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

Note: Fields marked with * are required

We will verify your coverage, and if necessary arrange payment for services not covered, or co-pay. Please bring your insurance card.

Contact Us Today!

Grace Acupuncture Clinic

Kingwood Office:

1525 Lakeville Dr. Suite #205,

Kingwood TX 77339

West Houston Office:

955 Dairy Ashford Rd., Suite #120,

Houston, TX 77079

Phone: (281) 671-7487

E-mail: info@graceacupunctureclinic.com

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Copyleft by Grace Acupuncture Clinic

Kingwood Office: 1525 LakevilleDr. Suite 205, Kingwood, TX 77339

West Houston Office: 955 Dairy Ashford Rd. Suite #120, Houston, TX 77079

Tel: 281-671-7487 Email: info@graceacupunctureclinic.com

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