Acupuncture Client Forms

You may download and fill out the forms listed below before arriving at your first acupuncture appointment. Please click on the name of each form to access the printable PDF of each form.

Health History Form


Acupuncture Client Information Form


Before and After Instructions


Insurance Coverage for Acupuncture

Blue Heron Wellness is pleased to be able to work with you and your health insurance carrier for coverage of your Acupuncture Services. We are in-network providers for Blue Cross/Blue Shield and Carefirst of the Mid-Atlantic. We will bill most other insurers on your behalf as an “out of network” provider (Cigna, Aetna and United Health Care). Please call your provider and find out whether they cover acupuncture by a licensed acupuncturist. Then call our office for more information. If you are covered by an insurer other than one noted above, we will provide the necessary codes and verification to enable you to bill you insurer for reimbursement.

Please Note: Blue Cross Blue Shield Clients

If you are a Blue Cross Blue Shield client, please complete the Acupuncture Insurance Verification and Statement of Financial Responsibility forms below before arriving at your first acupuncture appointment and bring your insurance card with you. Click on the links to access the printable PDF of each form.

Acupuncture Insurance Verification Form


Statement of Financial Responsibility