Insurance Verification Form Name (as stated on the insurance card)(required) Phone Email Date of Birth (MM/DD/YYYY)(required) Insurance Company Name(required) Member ID Number (not group number)(required) 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. *(required) Submit Δ Advertisement
Westport Counseling & Therapy 