Moonlight Therapies Request for Eligibility of Benefits

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Submit this form to have your benefits and details verified.

Phone Number *

Last Name *

First Name *

Date of Birth (mm/dd/yyyy) *

Insurance Company *

Insurance/Member ID Number *

Are you the primary subscriber? *

Yes

If, no, who is the primary insurance holder on your plan? What is your relationship to the primary insurance holder? (N/A if not applicable) *

In order to verify your benefit eligibility we must obtain and maintain protected health information from you. You have a right to understand our privacy practices and understand your rights to privacy. All information that you provide will be kept confidential unless required by law. Your medical information may be shared by Moonlight Therapies LLC, Nayely Trujeque, LMT and any of its authorized agents and employees. This order will remain in effect until revoked by me in writing. Your initials confirm that you have been informed of your rights to privacy regarding your protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). Our complete privacy practices and policies are listed online http://www.moonlighttherapies.com/privacy-policy and a written copy can be provided by request.

I have read and AGREE to the terms of the privacy policy listed above.

I have read and DISAGREE with the terms of the privacy policy listed above.

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