Insurance Coverage Checklist

To avoid unexpected out-of-pocket costs, we recommend calling the customer service number on the back of your insurance card and asking the following questions. You may want to write your answers directly in the spaces provided.

Provider Eligibility

• Is Dr. Ariel Touchet, ND, LAc in-network with my plan?
  ☐ Yes ☐ No

Naturopathic Office Visits

• Do I have a deductible?
  ☐ Yes ☐ No — Amount: ______________

• How much of my deductible has already been met? ______________

• Is there an out-of-pocket maximum?
  ☐ Yes ☐ No — Amount: ______________

• Are office visits subject to the deductible?
  ☐ Yes ☐ No

• Does my plan cover naturopathic medical visits?
  ☐ Yes ☐ No

• Is prior authorization required?
  ☐ Yes ☐ No

• Are there limits to naturopathic coverage (visit count or dollar limit)?
  ☐ Yes ☐ No — Details: ______________

• Is there a co-pay or co-insurance?
  ☐ Co-pay $__________ ☐ Co-insurance __________%

• Is CPT code 99354 covered?
  ☐ Yes ☐ No

Laboratory Services

• What percentage of lab costs are covered? __________%

• Are labs subject to the deductible?
  ☐ Yes ☐ No

• Which in-network labs can I use (e.g., Quest, Labcorp)? __________________

Acupuncture Coverage

• Does my plan cover acupuncture?
  ☐ Yes ☐ No

• Is prior authorization required?
  ☐ Yes ☐ No

• Are there limits to acupuncture coverage (visit count or dollar amount)?
  ☐ Yes ☐ No — Details: ______________

• Co-pay or co-insurance for acupuncture?
  ☐ Co-pay $__________ ☐ Co-insurance __________%

Massage / Holistic Pelvic Care

• Is CPT code 97140 covered?
  ☐ Yes ☐ No