Medicare Part B Validation Form

First name

Last name

Birthday

Month

Day

Year

SSN

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Second Arrow does not accept Insurance; however, there are special rules for Medicare Part B and Medicare Advantage (with out of network coverage).

You will still be charged each visit but at “a reduced rate” based on Medicare guidelines 2025 (2026 not yet updated). Medicare will potentially reimburse you for the payments you have made, per Medicare’s discretion.

Evaluation = $250 (you would be expected to pay estimated $182.70 or less)

Treatments: = $90 (you would be expected to pay estimated $75.62 or less, per treatment)

Signature

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