Liahona Academy Verification of Benefits Form Patient's Name* SSN* Date of Birth* MM slash DD slash YYYY Age*Address* City* State* Zip* Policy Holder's Name* Relationship to Patient* Policy Holder Phone* Policy Holder DOB* DD slash MM slash YYYY Employer of Policy Holder* Insurance Company* Insurance Co Phone (the number on the back of your insurance card)*ID* Group ID* Notes* Rx BIN* * I understand that Liahona Academy for Youth is an Out-of-Network Provider for all medical insurance providers and any insurance claims submitted by Liahona Academy for Youth will be done so under the Out-of-Network provision of your medical insurance coverage.
