Alternative Medicine Insurance Claim
Policyholder Name
Policy Number
Date of Birth
Phone Number
Email
Address
Treatment Provider Name
Treatment Provider Address
Treatment Type
Acupuncture
Chiropractic
Herbal Medicine
Homeopathy
Massage Therapy
Other
Date of Treatment
Total Claimed Amount (USD)
Description of Illness or Injury
Treatment Details & Notes
Supporting Documents (Invoice, Receipt, etc.)