Verification of Benefits

  • If you selected "Other" from the list above, please enter the diagnosis code here:
  • If you selected "Other" from the list above, please enter the diagnosis code here:
  • How did you find us?
  • (alternate location to consider if child is at babysitter or daycare during the day. Please write same as mother/father if address is same)
  • (Name of Parent Who Has The Insurance Plan)
  • Ex. Blue Cross, United, Aetna, etc.
  • This field is for validation purposes and should be left unchanged.