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 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 ID for the person who will be receiving therapy services, including any letters if part of the member ID. Thank you! We will verify your out-of-network benefits and be in touch.
