Insurance VerificationRafael Perez AP2016-10-23T11:22:40+00:00

By submitting this form, I understand that my personal information will be used ONLY for the insurance verification process. It will be accessible to Living Room Acupuncture and to a third-party biller.  All of our client information is confidential.  We do not share or sell any of or client information.

First and Last Name (required)

Your Email (required)
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Address (required)

City, State and Zip Code (required)

Your Telephone Number (required)

Your Birthdate (required)

Your Insurance Company (required)

Your Subscriber ID/Policy Number (required)

Group# (required)

Insurance Company Telephone (required)

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