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INSURANCE

Accepts
Insurance

Accepts
Insurance

Instructions

Please fill out the form below. Insurance verifications can take 3-5 business days. We will contact you by your preferred method.

*I only accept most BCBS plans. I do not accept Medicare.

Your first & last name

Email

Phone

Your name exactly as it appears on your insurance card (if different)

Date of Birth

Address

Primary Insurance Carrier

Member Number/ Member ID

Group Number

Are you the policy holder?

No

Yes

Policy holder name (if not you)

Policy holder date of birth

Your relationship to the policy holder

Do you have Medicare or secondary insurance? If yes, explain below

No

Yes

Employer

How did you hear about us?

Friend, family, or client of ours

Internet search

Google/Search engine

Blue Cross Directory

Dr. Streb

Another Healthcare Provider

Facebook

Instagram

Other

How do you want us to contact you?

Email

Text

Phone

Additional Comments

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

Questions?

Allow me to answer your questions. Send a message below.

First Name

Last Name

Email

Thanks for submitting!

Message

2024 by Brennecke Acupuncture, P.C.

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