Out-of-Network Benefits Form — Greta Bellinger Counseling

Out-of-Network Benefits

Interested in checking your out-of-network benefits? Fill out the form below, and we will get back to you with the results!

Client Name

First Name

Last Name

Client Email

Client Phone

(###)

###

####

Client Date of Birth

MM

DD

YYYY

What services are you interested in?

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Primary Insured's Name

Primary Insured's Date of Birth

MM

DD

YYYY

Insurance Company Name

Member ID Number