I authorize Bee Cave Acupuncture, to the fullest extent possible, the right to bill and receive payment from any third-party insurance, as well as Medicare, Tricare, or any other Federal or State benefits program, for services provided by Bee Cave Acupuncture. I request that my insurance carrier make payment directly to Bee Cave Acupuncture for services rendered to me. I also authorize and assign the right to Bee Cave Acupuncture to pursue any claim, appeal, right, or cause of action, including any claims that may be brought pursuant to ERISA (including claims for breach of fiduciary duty, declaratory and injunctive relief) and, if necessary, litigation against any ERISA-regulated plan. 

While Bee Cave Acupuncture will bill insurance on my behalf, I understand that I am ultimately financially responsible for all charges. All procedures are subject to any applicable copays, deductibles and/or coinsurance. If my insurance plan requires a referral, I understand that it is my responsibility to ensure that a referral from my primary care doctor is obtained prior to my medical visit(s). I will be financially responsible for charges associated with medical services if the proper referral has not been obtained and if permitted by my insurance contract. If a referral is not obtained prior to your visit, our staff will try their best to inform you and help you. reschedule your appointment.