Dr. Sima Aidun is a Naturopathic Doctor, focusing on women's health issues from puberty to menopause. Her practice is located in Scottsdale Arizona and she serves cities of Scottsdale, Gilbert, Chandler, Tempe,mesa, Glendale, Sun City, paradise Valley, Apache Junction, Queen Creek, and the greater Phoenix area.

Natural solutions for women

Guide to fill out generic insurance form: HICFA 1500

Please note that this guide has been put together with the most accurate information available in order to increase the chance of reimbursement from your insurance company. Our advice to you is to make sure to complete the form according to the information provided. If not, insurance company will not process your application. To fill out this form,You need to have the superbill provided to you at the time of your visit(s) in front of you.

1. Box 1: mark the type of insurance you have, usually group health plan, but depends on individual cases

2. complete 1a: insured I.D. Number which is ID#, Policy #, name of the insurance e.g: humana

3. complete Boxes # 2,3, 4,5,6,7,8, (9 if indicated)

4. BOX 10:the answer to all 3 (a.b,c) is NO

5. Box 11: group number, account #

6. Box 11a: employer name

7. Box 11c: insured plan name or program:e.g secure horizon

8. Box 12: sign and date

9. DO NOT SIGN BOX 13, IF YOU DO, THE INSURANCE COMPANY WILL SEND THE CHEK TO US

10. Box 14: date of the first visit for that specific health condition, for instance if you were seen for Problem x, and later on for a new problem Y, the date for each one is different

11. Box 15, 16, 17, 18, 19, can leave blank,Box 20:YES

12. Box 21: important: in front of each number write down your ICD-9 code ( will be on your superbill, given at the time of your visit)

13. BOX 22,23: Leave blank

14. Box 24:

a. 24A: date of the service

a. If you were seen for multiple acupuncture treatments for instance, all for the same reason and with the same ICD-9 codes, write down from: the first day to the last day of the treatment. you cannot combine dates of two different types of visits with different pricing, for instance you cannot combine acupuncture and well women exam and write it under #1. Acupuncture will be item 1 and well women item 2. Across from each date of service, make sure you fill out both FROM & TO sections for eash visit. For instance, if you were seen for consult on 11/11/08, the dates for both "From" and "TO" will be 11/11/08.

b. 24B: place of service: 11

c. 24D: Procedures, services: if office visit 99212 or any other number circled on your super bill under the consult. if acupuncture: 97811. You can find The procedure Code or CPT Code on your superbill given to you at the time of your service.

d. 24 E: Diagnosis pointers: refers to box 21. If you have an ICD number in front of number one, you just enter 1 in this box. if you have 3 ICD-9’s, you need to enter: 1,2,3

e. 24 F: charges: is per visit. Make sure if each line contains more visits, all are the same type with same unit price: all acupuncture for the same condition, or all iv…

f. 24.G: days or units: number of visits

g. 24.H and I: leave blank

h. 24. J: write down Dr. Aidun’s NPI address on the super bill, on the very top

15. BOX25: tax ID number of Dr. Aidun: at the very top of the super bill submitted to you by us at the time of your visit:

16. Box: 26 leave blank

17. Box: 27: mark No

18. Box: 28, 29, 30: per explanation

19. Box 31: blank

20. Box 32 :Dr. Aidun’s address/phone number

21. box 33: Patient's address/phone number

21. box 32a and 33 a: NPI: on the top part of the super bill

Please give us a call if you have any questions.