INSURANCE VERIFICATION FORM

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Before using your insurance for your visits at OCA, we'll need to verify your coverage. Please fill out the form below. We'll be in touch within 5 business days with the details of your coverage including your deductible, copay, and how many visits are covered under your plan.

*****Please not that you'll only be able to use your insurance for visits with practitioners who are signed on with your insurance plan. You may still see practitioners who are not signed on with your insurance but will need to pay out of pocket for those visits. We are working to get all our practitioners signed up with all carriers, however it is a LONG process! Thank you for your understanding and patience.

As of Fall 2024, Jennifer Taylor is signed up with :

UHC, CIGNA, SUTTER, VA, KAISER EMPLOYEE

As of Fall 2024, Christopher Randle is signed up with :

UHC, BLUE SHIELD/BLUE CROSS, SUTTER, VA, KAISER EMPLOYEE

Email *

FIRST NAME AS IT APPEARS ON YOUR INSURANCE CARD *

LAST NAME AS IT APPEARS ON YOUR INSURANCE CARD

Gender listed on your insurance card *

Female

Male

Nonbinary

DATE OF BIRTH (MM/DD/YYYY) *

STREET ADDRESS *

CITY *

STATE *

ZIP CODE *

YOUR PHONE NUMBER *

INSURANCE PROVIDER *

UNITED HEALTHCARE (ONLY JENNIFER TAYLOR, CHRISTOPHER RANDLE, DR.CALI JAMES))

SUTTER SELECT ( (ONLY JENNIFER TAYLOR, CHRISTOPHER RANDLE, DR. CALI JAMES)

BLUE CROSS/ BLUE SHIELD (ONLY CHRISTOPHER RANDLE)

CIGNA (ONLY JENNIFER TAYLOR, DR.CALI JAMES, DR.EMILY LEAP)

KAISER EMPLOYEE, MUST HAVE A Q9 ID (ONLY JENNIFER TAYLOR & CHRISTOPHER RANDLE)

MEMBER ID # *

GROUP NUMBER *

PROVIDER PHONE NUMBER LISTED ON BACK OF CARD: *

Are you the Primary card holder? *

Yes

If not, please list the Full Name and Date of Birth of the Primary card holder on the account.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Oakland Community Acupuncture.

Does this form look suspicious? Report

Forms