Document Library

Published by American Acupuncture Council Info Network on

1500 Claim form

      • 1500 02-12 With Calculations(Sign up to download.)
      • 1500 Claim Form Instruction Manual 2019 07-v7(Sign up to download.)

      COVID Forms

          • COVID-19 - CDC Health Professionals Guidelines(Sign up to download.)
          • COVID-19 - CDC Stop The Spread Flyer(Sign up to download.)
          • COVID-19 Informed Consent Form(Sign up to download.)
          • COVID-19 Office Safety Protocols(Sign up to download.)

          CPT - Modifiers, Injections, Prolonged Services, Miscellaneous Services

              Correspondence & Fight Back Letters

                  Denial of E&M with Acupuncture

                • Denial Of E&M Code Billed With Acupuncture PDF(Sign up to download.)

                  • Insurance Disputing Fees

                • Usual Customary And Reasonable Fee Reduction (editable)(Sign up to download.)
                • Usual Customary And Reasonable Fee Reduction PDF(Sign up to download.)

                  • Insurance requesting a refund

                • Insurance Requesting A Refund (editable)(Sign up to download.)
                • Insurance Requesting A Refund PDF(Sign up to download.)
                • Insurance Requesting A Refund, Extended Response PDF(Sign up to download.)

                  • Maintenance and Medical Necessity Denials

                • Acupuncture Medical Necessity Denial PDF(Sign up to download.)
                • Maintenance Care Denial (editable)(Sign up to download.)
                • Maintenance Care Denial PDF(Sign up to download.)

                  • Patient Collection

                • Patient Late Pay When They Receive The Check (PDF)(Sign up to download.)
                • Patient Late Pay When They Receive The Check (editable)(Sign up to download.)
                • Patient Late Pay When They Receive The Check(Sign up to download.)
                • Patient Late Pay (PDF)(Sign up to download.)
                • Patient Late Pay (editable)(Sign up to download.)

                  • Personal Injury

                • Attorney Holding Med Pay(Sign up to download.)
                • Attorney Holding Med Pay(Sign up to download.)
                • Attorney Late Payment With Signed Lien(Sign up to download.)
                • Attorney Late Payment With Signed Lien(Sign up to download.)
                • Attorney Status Of Claim(Sign up to download.)
                • Attorney Status Of Claim(Sign up to download.)
                • Attorney Cover Letter With Lien(Sign up to download.)
                • Attorney Cover Letter With Lien(Sign up to download.)
                • Attorney Negotation To Reduce Settlement Rejection(Sign up to download.)
                • Attorney Negotation To Reduce Settlement Rejection(Sign up to download.)
                • Attorney Not Paying Settled Claim(Sign up to download.)
                • Attorney Not Paying Settled Claim(Sign up to download.)
                • Attorney Paying Reduced Amount Rejection(Sign up to download.)
                • Attorney Paying Reduced Amount Rejection(Sign up to download.)
                • Deposition Expert Witness Fees(Sign up to download.)
                • Deposition Expert Witness Fees(Sign up to download.)
                • Excess Med Pay HMO Primary(Sign up to download.)
                • Excess Med Pay HMO Primary(Sign up to download.)
                • Excess Med Pay No Primary Health Insurance(Sign up to download.)
                • Excess Med Pay No Primary Health Insurance(Sign up to download.)
                • Patient Late Payment Of Settled Claim 2(Sign up to download.)
                • Patient Late Payment Of Settled Claim 2(Sign up to download.)
                • Patient Late Payment Of Settled Claim(Sign up to download.)
                • Patient Late Payment Of Settled Claim(Sign up to download.)

                  • Termination of PPO Contract

                • Termination Of PPO Contract (PDF)(Sign up to download.)
                • Termination Of PPO Contract (editable)(Sign up to download.)

                  • Timely Filing Dispute

                • Timely Filing Dispute (PDF)(Sign up to download.)
                • Timely Filing Dispute (editable)(Sign up to download.)

                  • Withdrawal from care

                • Withdrawal From Care (PDF)(Sign up to download.)
                • Withdrawal From Care (editable)(Sign up to download.)

                  • Documentation

                      • Documentation Of Acupuncture(Sign up to download.)
                      • Sample Acupuncture SOAP Note(Sign up to download.)
                      • Sample Acupuncture SOAP Note(Sign up to download.)
                      • Template Acupuncture SOAP Note(Sign up to download.)

                      External Causes of Injury ICD9 & ICD10 Codes

                          • E Codes ICD9 External Causes Of Injury(Sign up to download.)
                          • V Codes ICD10 Auto Accidents(Sign up to download.)
                          • V, W, X, Y, & Z Codes ICD 10 Morbidity & Health Status Codes(Sign up to download.)

                          Financial Agreements

                              Cash and-or Insurance

                            • Financial Policy & Agreement (PDF)(Sign up to download.)
                            • Financial Policy & Agreement (editable)(Sign up to download.)

                              • Credit Card Authorization

                            • Credit Card Authorization For Past Due Payments(Sign up to download.)

                              • Financial Hardship

                            • Financial Hardship Agreement (PDF)(Sign up to download.)
                            • Financial Hardship Agreement (editable)(Sign up to download.)

                              • Insurance

                            • Health Insurance Acupuncture (PDF)(Sign up to download.)
                            • Health Insurance Acupuncture (editable)(Sign up to download.)

                              • Personal Injury (auto accidents)

                            • Personal Injury Financial Agreement (PDF)(Sign up to download.)
                            • Personal Injury Financial Agreement (editable)(Sign up to download.)

                              • Surprise Billing

                            • Financial And Good Faith Acupuncture IN NETWORK(Sign up to download.)
                            • Financial And Good Faith Acupuncture OUT OF NETWORK(Sign up to download.)

                              • Forms (History, exam, consultation, lien, assignment of benefits)

                                  Assignment of Benefits

                                • Assignment Of Benefits(Sign up to download.)

                                  • History, Consultation & Examination

                                • Case History 7.13.21(Sign up to download.)
                                • Personal Injury Intake 7.13.21(Sign up to download.)
                                • Review Of Systems(Sign up to download.)

                                  • Personal Injury Lien

                                • Notice Of Doctors Lien 7.13.21(Sign up to download.)

                                  • HCPCS Orthotics and DME Common Codes

                                      • HCPCS Common Codes(Sign up to download.)

                                      HIPAA Privacy Notices

                                          • Business Associate Agreement Acupuncture (editable)(Sign up to download.)
                                          • Business Associate Agreement Acupuncture PDF(Sign up to download.)
                                          • HIPAA Privacy Notice (editable)(Sign up to download.)
                                          • HIPAA Privacy Notice PDF(Sign up to download.)
                                          • Request For Records(Sign up to download.)

                                          Informed Consent

                                              • Acupuncture Arbitration Agreement And Informed Consent - FED(Sign up to download.)
                                              • Informed Consent Acupuncture - California(Sign up to download.)
                                              • Informed Consent Acupuncture- Federal(Sign up to download.)

                                              Insurance Acupuncture Coverage Policies

                                                  Aetna

                                                • Acupuncture Clinical Policy Bulletin 0135 2021(Sign up to download.)

                                                  • Blue Cross and Blue Shield

                                                • Anthem Acupuncture Clincal Guideline CG-ANC-03(Sign up to download.)
                                                • Excellus Blue Cross Blue Shield Acupuncture Policy(Sign up to download.)
                                                • Regence Blue Cross Blue Shield Acupuncture Coverage(Sign up to download.)

                                                  • Cigna

                                                • Acupuncture - Cigna Medical Coverage Policy 2023-2024(Sign up to download.)

                                                  • Evicore-Anthem-Optum

                                                • Evicore Acupuncture Guidelines 2020(Sign up to download.)

                                                  • Health Net

                                                • Health Net Acupuncture(Sign up to download.)

                                                  • HealthPartners

                                                • Health Partners Acupuncture Coverage 2020(Sign up to download.)

                                                  • United Health Care

                                                • United Health Care Acupuncture Policy(Sign up to download.)

                                                  • Insurance Billing Protocol and Sample Bills

                                                      • Acupuncture Insurance Billing Protocol Step-by-Step(Sign up to download.)
                                                      • Group Practice Or Corporation Acupuncture Billing(Sign up to download.)
                                                      • Initial Acupuncture Visit - E&M With Acupuncture(Sign up to download.)
                                                      • Subsequent Acupuncture Visit With Multiple Units Of Acupuncture(Sign up to download.)
                                                      • Subsequent Acupuncture Visit With Therapy(Sign up to download.)
                                                      • Subsequent Acupuncture Visit(Sign up to download.)

                                                      Insurance Verification Form

                                                          • Insurance Verification Acupuncture(Sign up to download.)

                                                          Outcome Assessments & Disability Indexes

                                                              Balance

                                                            • Balance Test - Tinetti(Sign up to download.)
                                                            • Berg Balance Scale(Sign up to download.)

                                                              • Concussion

                                                            • Acute Concussion Evaluation(Sign up to download.)

                                                              • Depression

                                                            • Depression Assessment(Sign up to download.)

                                                              • Extremities

                                                            • Disabilities Of The Shoulder And Hand(Sign up to download.)
                                                            • Lower Extremity Functional Scale(Sign up to download.)

                                                              • Gait

                                                            • Gait Assessment - Tinetti(Sign up to download.)

                                                              • Headache

                                                            • Headache Disability Index(Sign up to download.)

                                                              • Pain & Health Survey

                                                            • Fear Avoidance Behavior Questionnaire(Sign up to download.)
                                                            • Fear Avoidance Beliefs Questionnaire(Sign up to download.)
                                                            • General Pain Index(Sign up to download.)
                                                            • McGill Pain Questionnaire(Sign up to download.)
                                                            • McGill Short Form(Sign up to download.)
                                                            • Pain Scale With General Pain Index(Sign up to download.)
                                                            • Patient-specific-functional-scale(Sign up to download.)
                                                            • Picture Pain Disability(Sign up to download.)
                                                            • SF36 General Health Survey(Sign up to download.)
                                                            • SF36 Scoring(Sign up to download.)

                                                              • Pain and Function Scale Veterans

                                                            • VA Pain Rating Scale(Sign up to download.)
                                                            • VA Pain Supplemental Questions(Sign up to download.)

                                                              • Sleepiness Scale

                                                            • Epworth Sleepiness Scale(Sign up to download.)

                                                              • Spanish

                                                            • ADL - Spanish(Sign up to download.)
                                                            • Low Back Oswestry - Spanish(Sign up to download.)
                                                            • Low Back Roland Morris - Spanish(Sign up to download.)
                                                            • Neck Oswestry Spanish(Sign up to download.)
                                                            • VA Pain Rating Scale - Spanish(Sign up to download.)

                                                              • Spine

                                                            • Copenhagen Neck Disability(Sign up to download.)
                                                            • Neck Disability Index(Sign up to download.)
                                                            • Neck Disability Scoring Method(Sign up to download.)
                                                            • Oswestry Low Back Disability Index(Sign up to download.)
                                                            • Oswestry Scoring Method(Sign up to download.)
                                                            • Roland Morris (Low Back)(Sign up to download.)

                                                              • TMJ

                                                            • TMJ Questionnaire(Sign up to download.)

                                                              • Superbill

                                                                  • Acupuncture Superbill ICD10 Update 2022(Sign up to download.)

                                                                  Treatment Guidelines

                                                                      ACOEM

                                                                    • Ankle-and-Foot-Disorders-Guideline-1(Sign up to download.)
                                                                    • Cervical-and-Thoracic-Spine-Disorders-Guideline-1(Sign up to download.)
                                                                    • Elbow-Disorders-Guideline-1(Sign up to download.)
                                                                    • Hand-Wrist-and-Forearm-Disorders-Guideline(Sign up to download.)
                                                                    • Hip-and-Groin-Disorders-Guideline-1(Sign up to download.)
                                                                    • Initial-Approaches-to-Treatment-Guideline(Sign up to download.)
                                                                    • Low-Back-Disorders-Guideline-1(Sign up to download.)
                                                                    • Opioids-Guideline-1(Sign up to download.)
                                                                    • Opioids-Guideline(Sign up to download.)
                                                                    • Shoulder-Disorders-Guideline(Sign up to download.)

                                                                      • Acupuncture General Guidelines

                                                                    • Acupuncture Evidence Based Treatment Guidelines(Sign up to download.)
                                                                    • Acupuncture And Electroacupuncture TreatmentGuidelines(Sign up to download.)

                                                                      • Chronic Pain Disorder

                                                                    • Chronic Pain Disorder (searchable For Acupuncture)(Sign up to download.)
                                                                    • Non-Acute Pain Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)

                                                                      • Complex Regional Pain Syndrome

                                                                      Cumualtive Trauma

                                                                    • Cumulative Trauma Conditions (searchable For Acupuncture)(Sign up to download.)

                                                                      • Extremities

                                                                    • Carpal Tunnel Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)
                                                                    • Knee Injury Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)
                                                                    • Lower Extremity Injury (searchable For Acupuncture)(Sign up to download.)
                                                                    • Shoulder Injury (searchable For Acupuncture)(Sign up to download.)
                                                                    • Shoulder Injury Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)

                                                                      • Spine

                                                                    • Cervical Spine Injury (searchable For Acupuncture)(Sign up to download.)
                                                                    • Low Back Pain (searchable For Acupuncture)(Sign up to download.)
                                                                    • Mid And Low Back Injury Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)
                                                                    • Neck Injury Medical Treatment Guideline (searchable For Acupuncture)(Sign up to download.)
                                                                    • Thoracic Outlet Syndrome (searchable For Acupuncture)(Sign up to download.)