Out-of-Network Insurance Benefits Verification Name and email of person filling out this form * Name and email should match name and email you used to contact us. Member first and last name * Please input the legal name of the person who will be receiving therapy services. Member DOB * Please input the date of birth for the person who will be receiving services. Insurance company name e.g., Blue Cross Blue Shield, Cigna, Aeta, etc. Member ID * Unique member ID for the person who will be receiving therapy services, including any letters if part of the member ID. Please note this is different from the group ID and we do NOT need the group ID for verification. In order to check your out of network benefits, we submit the above information into a form through a platform called Thrizer. By checking the box below and submitting this form I give consent to Sawtelle Psychotherapy Group and Thrizer, LLC to access my insurance information to obtain insurance eligibility and benefits. * Yes, I give my consent Thank you! We will verify your out-of-network benefits and be in touch.
