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YOUR CART
Insurance Verification Request Form
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First Name
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Last Name
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Email
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Date of Birth
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Insurance Provider
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Aetna
Anthem
AvMed
Blue Cross Blue Shield
Cigna and Evernorth
Empire BCBS
Florida Blue
Humana
Meritain Health
New Directions
Optum
Oscar
UMR
United Healthcare
Other/Not Listed
Member ID
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Service(s) Requested
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Individual Therapy
Couples Therapy
Family Therapy
Hypnotherapy
EMDR
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I understand that this is a verification of benefits and not a guarantee of services.
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