Insurance & Intake Forms
Please fill out the form below on the right with your insurance information or note that you will be paying day-of-service. Once your benefits are verified (usually in two to three business days) you will be contacted with appointment times for your initial intake and treatment.
Then please print and fill out the initial intake forms below and bring them to your first appointment.
PLEASE NOTE: We cannot bill OHP, Medicaid, or Medicare policies.
For acupuncture coverage under Medicare Part B "The acupuncture must be provided by a licensed and qualified medical provider (MD or DO) who accepts Medicare." As a Licensed Acupuncturist we cannot receive reimbursement at this time.
Then please print and fill out the initial intake forms below and bring them to your first appointment.
PLEASE NOTE: We cannot bill OHP, Medicaid, or Medicare policies.
For acupuncture coverage under Medicare Part B "The acupuncture must be provided by a licensed and qualified medical provider (MD or DO) who accepts Medicare." As a Licensed Acupuncturist we cannot receive reimbursement at this time.
New Patient Request & Insurance Inquiry
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I am currently an in-network provider and accepting new patients with Providence (PEBB Only), Pacific Source (Commercial Only), Regence/BCBS, and Moda. As a courtesy, after each treatment I will submit reimbursement forms directly to your insurance provider, collecting requisite deductible or copay at the time of service. At this time I cannot bill Oregon Health Plan or Medicare for any services rendered. 9/1/25 - I am unable to bill Providence Commercial Plans at this time (PEBB/State plans are still billable). Please contact your insurance carrier to confirm coverage for your situation. If you have questions about your coverage or copay, please fill out the form below and we will help in any way that we can. Please note that you are ultimately responsible for payment, and that insurance billing is a courtesy that we gladly extended. Day-of-service rates are discounted rates contingent upon payment at the time of service. Retroactive insurance billing is not available to patients who choose to pay the discounted rate at the time of service. Insurance billing rates vary according to the length of your consultation, the medical complexity of your case, the length of your treatment, and additional necessary services (such as cupping, nutritional counseling or tui na). Please contact us about further day-of-service discounts for Students with valid IDs, Active Military and their families, Veterans, and Families associated with The Village School in Eugene, Oregon. |
New Patient Intake Forms
Please print and bring the appropriate forms to your initial appointment, fax completed forms to 855.778.5828, or email completed forms to [email protected] :
