Nadine Shozuya, L.Ac.
2140 Artesia Blvd. Unit A.
Torrance, CA  90504



Insurance Co:___________________________________________________________

Name of Insured:_____________________________________________ 


City:________________________ State:_____ Zip:____________

Group/Policy#:____________________________   D.O.B. _____________

Medicare Y___N___  Medicare#:____________   Retirement date:____________

Social Security No:____________________  Blue Cross/Blue Shield ID#____________

I hereby instruct the ____________________________Insurance Co. to pay by check made out to and mailed directly to:

Nadine Shozuya
2140 Artesia Blvd. Unit A.
Torrance, CA  90504

I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be referred to by Nadine Shozuya and any emergency transporting that may be required thereto.  I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in the case.

Patient or Insured Signature: ________________________________Date:__________