New Patient Request, Insurance & Intake Forms
Please fill out the form below with your preferred appointment times and 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 to schedule.
Then please print and fill out the initial intake forms below and bring them to your first appointment.
Then please print and fill out the initial intake forms below and bring them to your first appointment.
2026 Updates:
We can bill: MODA, Pacific Source (Commercial only), Providence (Pebb Only), Regence/BCBS (Federal or Oregon Only), and Motor Vehicle Accidents.
Regence BCBS of Oregon plans only cover 45 minutes of acupuncture. You will be responsible for a $40 surcharge in addition to your copay and deductible as we only offer 60 minute appointments.
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.
We do NOT submit insurance for patients from Trillium (Oregon Health Plan; OHP), Triwest/Tricare (VA), PacificSource Medicare Advantage plans, United Healthcare Medicare advantage plans, Providence Medicare Advantage plans, CIGNA, CHP Group, Kaiser, HealthNet, WellCare, Aetna, Providence (except Collective Health), or Workman's Comp.
Regence BCBS of Oregon plans only cover 45 minutes of acupuncture. You will be responsible for a $40 surcharge in addition to your copay and deductible as we only offer 60 minute appointments.
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.
We do NOT submit insurance for patients from Trillium (Oregon Health Plan; OHP), Triwest/Tricare (VA), PacificSource Medicare Advantage plans, United Healthcare Medicare advantage plans, Providence Medicare Advantage plans, CIGNA, CHP Group, Kaiser, HealthNet, WellCare, Aetna, Providence (except Collective Health), or Workman's Comp.
New Patient Request & Insurance Inquiry
Please contact your insurance carrier to confirm coverage for your situation.
Please note that you are ultimately responsible for payment, and that insurance billing is a courtesy that we gladly extend. 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).
I am currently an in-network provider 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, per my contract with your provider.
Please note that you are ultimately responsible for payment, and that insurance billing is a courtesy that we gladly extend. 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).
I am currently an in-network provider 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, per my contract with your provider.
New Patient Intake Forms
Please print and bring the appropriate forms to your initial appointment or email completed forms to [email protected] :
