New Patient Contact / Insurance Intake Form First Name(Required) Given Name Last Name(Required) Surname Address(Required) Street Address Address Line 2 City ZIP Code Phone(Required)Email(Required) DemographicsPatient's Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Transgender (male/female/other) Non-binary Other Marital Status(Required) Single Married Separated Divorced Widowed Fulltime Student(Required) Yes No EmploymentEmployment Status(Required) Fulltime Part-time Unemployed Employer Name(Required)Employment Position(Required)InsurancePrimary Insurance(Required)–No Insurance / Self PayAetnaBlue Cross Blue ShieldCignaUnitedHealthOptum Community Care NetworkPatient's Relationship to Insurance Holder(Required)–SelfSpouseChildOtherPrimary Insurance Holder's Name(Required)Primary Insurance Holder's Date of Birth(Required) MM slash DD slash YYYY Consent(Required) I agree to the following terms and conditions:1) Healthy Roots Medicine, Inc. (HRM) is an in-network provider with Aetna, CareFirst (BCBS), Cigna, and UnitedHealth 2) If the patient’s insurance policy has acupuncture benefits, HRM will bill the insurance carrier to facilitate the processing of claims 3) The patient consents to (HRM)’s provider(s) to render treatment and apply for acupuncture benefits if included in their insurance policy 4) The patient consents to the release of any medical or other information necessary to process claims and their subsequent payment 5) The guarantor is the insurance policy holder; which will be responsible if their insurance company declines to pay the claim for any reason Δ