In order to verify your insurance coverage for therapy services, specifically your out-of-network benefits, we will be reaching out to your insurance company on your behalf. To facilitate this process, we kindly ask that you provide the following details as listed on your insurance card:

Patient Information

Name

First Name

Last Name

Email

Date Of Birth

MM

DD

YYYY

Policy Holder Information

Primary Subscriber

Insurance Carrier

Member ID Number

Policy Holder Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If the primary subscriber differs from the insured individual, please provide their information as well.

Alternatively, you may send a clear image of both the front and back of your insurance card for our reference.

Once we have received confirmation of your out-of-network benefits, we will share the details provided by your insurer, along with a reference number for your records.

Thank you for your cooperation in ensuring that we can provide you with the most accurate and timely information regarding your coverage. Should you have any questions or need further assistance, please don’t hesitate to reach out.

Insurance Form