Reimbursement Forms for Insurance & FSAs

We provide complete documentation to help you get reimbursed through your out-of-network health insurance or Flexible Spending (FSA) / Health Savings Account (HSA).

Quick Guide:

• For Health Insurance Claims: Use the forms in Section 1. They contain all required medical codes (CPT, ICD-10) and legal details.

• For FSA/HSA Reimbursements: You can use the simple receipt in Section 2 or your insurance form from Section 1. The Section 2 form is also for wellness product purchases.

Section 1: Health Insurance Reimbursement Forms

Our forms are complete "superbills." Just add your Date of Service, Name, and Date of Birth and submit the correct PDF directly to your insurer.

⚠️ Critical: You MUST Use the Correct Form

Insurance fraud occurs if you submit a claim for an amount you did not pay. Using a form with an incorrect fee (e.g., using a $250 form for a packaged session you bought for $100) can result in claim denial, recoupment, or legal issues. Please select carefully.

Download Your Form by Session Type

A. The Foundation Session (Individual Session)

• Service: 75-minute comprehensive intake & treatment.

• CPT Codes: 97810 + 97811 (Total 60+ min of acupuncture)

• Total Charge: $250.00

• [Download Foundation Session Form (PDF)]

B. Integration Sessions (75-min deep work)

• Individual Session Price: $195.00

  • [Download Individual Integration Session Form (PDF)]

• Pre-Purchased Package Price (Per Session):

  • 3-Pack: $185.00 per session [Download Form (PDF)]

  • 6-Pack: $180.00 per session [Download Form (PDF)]

  • 12-Pack: $175.00 per session [Download Form (PDF)]

C. Reset & Restore Sessions (45-min tune-up)

• Individual Session Price: $125.00

  • [Download Individual Reset & Restore Form (PDF)]

• Pre-Purchased Package Price (Per Session):

  • 3-Pack: $120.00 per session [Download Form (PDF)]

  • 6-Pack: $115.00 per session [Download Form (PDF)]

  • 12-Pack: $110.00 per session [Download Form (PDF)]

D. The Grounding Protocol (30-min back treatment)

• Service: 30-minute Aggressive Energy Clearing / Tree of Life protocol.

• CPT Code: 97810 (Initial 15 min only)

• Total Charge: $65.00

• [Download Grounding Protocol Form (PDF)]

Section 2: FSA / HSA Reimbursement Receipt

Use this simple receipt form for your FSA or HSA administrator. It's ideal for acupuncture services (use this or the insurance form above) or the purchase of eligible wellness products (e.g., herbs, topicals, heat packs).

• [Download General FSA/HSA Receipt Form (PDF)]

FAQs & Important Details

Before You Submit:

1. Contact Your Insurer: Call the number on your card to confirm your out-of-network acupuncture benefits, deductible, and how to submit claims (mail, online portal, fax).

2. Use the Exact Form: Match the form to the session type and price you actually paid, as shown on your receipt.

Common Questions:

• What if I need a different diagnosis code? Our standard form lists M54.50 (Low Back Pain). For a different primary diagnosis, email Info@BodyMechanics.com for an adjusted form.

• I bought a package. Which date do I use? Use the actual date of each specific visit on that session's form.

• Are my services/products FSA/HSA eligible? Acupuncture is typically eligible. Product eligibility varies by plan. When in doubt, submit the receipt and let your administrator decide.

• Can I re-download a form? Yes, all forms are available here for one year from your service date.

Our Provider Information:
All forms include this pre-filled detail for your insurer’s reference.

• Provider: Tabitha Silver, LAc

• Practice: Body Mechanics Acupuncture | 2807 Broadway, New York, NY 10025

• Phone: (347) 699-0858

• NPI: 1285019232 | Tax ID: 88-786071 | NY License: 005270

Disclaimer: These forms are provided to assist you. Reimbursement is a contract between you and your insurer or FSA/HSA administrator. We cannot guarantee payment. You are solely responsible for submitting accurate information and complying with your plan's rules.

For questions about these forms, please email Info@BodyMechanics.com.