Out-Of-Network Insurance Benefits Verification Name of person filling out this form * Name should match the name you used to contact me First Name Last Name Email Email should match the email you used to contact me 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 therapy services Insurance company name * e.g. Aetna, Anthem Blue Cross, United Healthcare, 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. First Name Last Name In order to check your out of network benefits, I submit the above information into a form through a platform called Thrizer. By checking the box below, you are confirming that you (1) understand this is an estimate and that your benefits may change at any time based on your insurance plan and (2) give consent to Alexa Golding Marriage and Family Therapy, Inc. and Thrizer, LLC to access my insurance information to obtain insurance eligibility and benefits. Yes, I understand and give my consent. Thank you!
