Check my out-of-network benefits

Upload your insurance card and a few details. We call your insurer, then explain what we learned and your estimated cost.

Back to Get in Touch

Check my out-of-network benefits

Upload your insurance card and a few details. We call your insurer, then explain what we learned and your estimated cost.

Back to Get in Touch

Check my out-of-network benefits

Upload your insurance card and a few details. We call your insurer, then explain what we learned and your estimated cost.

POLICYHOLDER

Policyholder first name (as on card)

Policyholder last name (as on card)

Policyholder date of birth

Month

Day

Year

Relationship to child

YOUR CHILD

Child’s full name

Child’s date of birth

Month

Day

Year

Does your child have a diagnosis? (optional)

Yes

No

In process

CONTACT

Email

Phone

INSURANCE

Insurance company

Insurance card – front

Image or PDF

Insurance card – back

Image or PDF

I authorize Bianna Shamis ABA Services PLLC, d/b/a GEMS Play & Connect, to contact my insurance company and share the information in this form, including my insurance card, to verify out-of-network benefits for ABA services for my child.

I understand that verification is not a guarantee that my insurer will pay a particular claim.

Your information is sent securely and used only to verify your benefits.