We are looking forward to meeting you! Welcome. Below you will find our New client forms and paperwork. You can either download the PDF or fill them out online in your JANE account prior to your appointment. If we will be billing your health insurance plan, please bring your insurance ID card with you to your session.
There is nothing special that you need to wear, avoid or do before your acupuncture. We suggest loose stretchy clothing, but we have sheets and gowns available too. If you have further questions that we could answer for you, please call/text or email us: 425-533-7320 or bellevueacupuncture@gmail.com.
FORMS FOR ALL NEW PATIENTS
Fill out online in your JANE account or download the PDF here to print at home. If you would prefer to fill them out at our clinic, please arrive 15 minutes early.
PIP/MVA AUTO ACCIDENT FORM
For submitting medical claims related to injury received in an MVA, please fill out or download and complete this additional form. Thank you.
Insurance
It is your responsibility to know your insurance coverage.
Please see below for the questions to ask your insurance company if you plan on utilizing your healthcare insurance for covering your acupuncture sessions.
Information received from your insurance is a quote of benefits and it is not a guarantee of coverage or payment. You are personally responsible for any unpaid balances regardless of the information we have received from your company.
Insurance companies often provide incorrect, incomplete or misleading information.
Your insurance can also change their policies related to coverage without any notification.
Please be aware of your annual visit benefit/visit maximums through your insurance, often a maximum of 12 or 24 sessions per year.
Common Questions to ask your insurance about your coverage:
- Note the date, person you spoke with and get a call reference # at the end of the call.
- Do I have acupuncture coverage and benefits for CPT codes 97810 and 97811?
- How many acupuncture visits are covered per calendar year?
- Is my acupuncture benefit subject to my in or out of network annual deductible?
- Is the acupuncture benefit (visit count #) combined with any other services such as PT, chiropractic or massage?
- Does my policy cover the condition I want to be seen for?
*Some acupuncture benefits only cover acupuncture for chemotherapy related nausea or low back pain conditions.
- Is a copayment required for the office visit (which you will have on your first visit and with any follow-up visits for a new condition?
Is my acupuncturist in-network? Our NPI to ask about our specific clinic ( national provider number) is:
Kaira Jorgensen NPI #1861475543
If we are Out of network:
Most out of network clients use their HSA cards for acupuncture.
- Do I have out of network benefits and coverage for acupuncture?
- Do I have an out of network deductible that is separate from my in-network deductible?
- What $ amount will I be responsible for after the insurance processed my acupuncture visits?
- Do I have an out of network co-pay?
It is helpful to clarify if you have a copayment, coinsurance, out of network deductible, and/or all of them applied to each visit.
We are in-network with:
- Aetna
- Premera
- Lifewise
- BC/BS plans
- Regence
- PIP (auto injury cases)
Our Cancellation Policy:
We ask that you notify us 48 hours before your scheduled appointment should you need to cancel. If you need to cancel your appointment with less that 48 hours’ notice, you may be charged a fee.
We will not be able to offer our time-of-service discount after insurance has been billed, in the event that your insurance denies the claim or when you have met your annual visit maximum. It is your responsibility to monitor your annual calendar visit count.
If we bill your insurance and the insurance denies your claims, the charges below are the charges that may be billed you:
- New patient visit range: $285-$385 depending on services rendered
- Return patient visit: $165-$235
We Do NOT bill insurance for the following insurance companies:
- Apple Care
- First Choice
- Kaiser
- Cigna
- Humana
- L & I claims
- Medicare
- TriCare
- United Healthcare
