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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.

Please keep in mind that I ONLY bill to BCBS, and only when it is the Primary Insurance on file. I do not accept Medicare at this time. I cannot bill to Blue Cross Blue Shield when Medicare is the Primary insurance.

Your first & last name

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

Email

Phone

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

Wellness Center

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!

Next Step: Book Appointment

Questions?

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

First Name

Last Name

Email

Thanks for submitting!

Message

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Address

Phoenix Park
2 Shaker Rd. Suite B222
Shirley, MA

Call/Text: 978-571-9772

2025 Victoria Brennecke Acupuncture

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