Dr. Fan Insurance Verification Form

Please complete the information below. Once we receive confirmation of your benefits from your insurance company, we will contact you as soon as possible to schedule your appointment.

First Name

Last Name

Date of Birth

Phone Number

Email Address

Upload Insurance Card - Front and Back Please upload two clear images: the front and back of your insurance card.

Add file

Please upload a file

Reason for Visit

I understand that insurance verification is not a guarantee of coverage or payment. I authorize Fan Acupuncture Health to use the information provided to verify my insurance benefits and contact me regarding appointment scheduling.

Your information will be encrypted.