Out Of Network Benefits Verification Form

Client's Name

Client's Date of Birth

Client's Email

Client's Phone

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Therapist

Tell Us More (Issues to Address, Preference in Therapy Types, etc...)

Primary Insured's Name

Primary Insured's Date of Birth

Insurance Company Name

Member ID Number

Please upload a picture of the front and back of your insurance card.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.