Westport Counseling & Therapy

Insurance Verification Form

Name (as stated on the insurance card)

Phone

Date of Birth (MM/DD/YYYY)

Insurance Company Name

Member ID Number (not group number)

Insurance Provider Phone Number (located on the back of the insurance card)

By signing my name below, I hereby give Westport Counseling & Therapy permission to look up my insurance benefits and relay them to me. *