Anthem Blue Cross/Aetna Benefits Check Request
Thank you so much for reaching out to us.  If you are hoping to use Anthem Blue Cross or Aetna in network coverage, please provide your insurance details on this form so we can verify your co-pay and coverage for you.   Unfortunately, we are not able to accept Medi-Cal at Greenhouse Therapy Center. 

Please only fill out this form if requested to do so by Greenhouse Therapy Center. 

Please fill in one form per new client.

Rebecca Garcia, Inquiries Coordinator
hello@greenhousetherapycenter.com
Sign in to Google to save your progress. Learn more
Name of Greenhouse staff member that requested this form:
*
Name of new client (person to start receiving services). Please list full legal name as is listed on insurance policy.  
*
Email address (parent/caregiver email if client is a minor)
*
Client date of birth
*
MM
/
DD
/
YYYY
Client legal sex
*
Client address (including city, state, and zip code)
*
Client phone number
*
Insurance provider (we are not able to accept Medi-Cal) *
Subscriber name
*
Subscriber date of birth
*
MM
/
DD
/
YYYY
Client's relationship to subscriber *
Member ID (including any letters)
*
Group # *
Effective date *
MM
/
DD
/
YYYY
Subscriber home address (if different from the client)
Insurance company's provider service phone number (may be located on back of insurance card)
*
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Greenhouse Therapy Center.