First Name *

Last Name *

Phone *

Date of birth *

Email *

Text Message Language Radio Box *

English (standard)

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How did you hear about us? (Referral Information)

If referred by a medical provider, please let us know who referred you so we can coordinate care

Insurance Company Carrier *

Aetna, Cigna, Anthem Blue Cross, Kaiser, Etc.

Insurance Member ID *

Include any letters in the member ID.

Group Number

Primary policyholder name & date of birth

Patient relationship to primary policyholder

Self, Spouse, Child

Private Pay Non-Insurance Service(s) you're seeking: Select all that apply

Insurance-Covered Service(s) you're seeking: *

Traditional Acupuncture

Electro-Acupuncture (E-Stim)

Myofascial Cupping Therapy (if covered)

Select all that apply

Which Provider(s) would you like to see? *

Dr. Aaron Lee (Licensed Acupuncturist He/Him) English

Dr. Eric Sun (Licensed Acupuncturist He/Him) English, 普通话流利

Dr. Charlie Hsu (Licensed Acupuncturist He/Him) English, 普通话流利

Dr. Jackie Chan (Licensed Acupuncturist She/Her) English, 普通话流利

Dr. Supreeth Shivakanth (Licensed Acupuncturist, He/Him) English, Hindi

Dr. Juweria Vora (Licensed Acupuncturist, She/Her) English, Hindi, Urdu, Spanish

Visit below for bios, network status & specialty

Which Massage Therapy Provider(s) would you like to see?

Justin Ewaska (Massage Therapist, He/Him) English

Visit below for bios, network status & specialty

Preferred day/times

Weekdays (morning/afternoon/early evening)

Weekends (Sat/Sun)

Choose the best block and day that work for your schedule

Insurance Benefits Disclaimer: Most benefits require that the chief complaint be a "covered condition" under the health plan's medical policy bulletin for acupuncture. Covered conditions are 99% related to musculoskeletal conditions like neck and low back pain, shoulder pain, arthritis, etc. and very rarely cover Fertility Treatments, Pelvic Floor Disorders, Relaxation and Mental Health Disorders. Do you understand that if your chief complaint is not billable or covered, that you may need to pay out of pocket for a treatment. We will be more than happy to provide you a superbill if this is the case. *

Yes

No

Verification of benefits are not a guarantee of payment or coverage, all coverage and benefit limits will be determined once the insurance claim is paid out. Do you understand that by using your insurance benefits, there is a risk that you may need to pay out of pocket for your entire treatment? *

Yes

No

Insurance coverage is a confusing and complex field, the statement listed above is the standard statement that insurance tells us as providers, we are only passing this statement along to you.

Quick Office Policy Rundown: Credit Card on file is required at the time of booking. If you do not have a valid credit card, we will still book you in, but if you miss your first appointment (unless due to emergency) you will no longer be allowed to be seen at our clinic. Late cancellations are less than 24 hours and late reschedules are 12 hours or less, your first late cancellation/reschedule will be a warning, but future ones will incur a $100 fee. Do you understand? *

Yes

No

Verify your Insurance Benefits for Acupuncture & Integrative Care