Insurance Verification Form

Submit your health insurance information for verification. All information is held confidential.
Fill in all required fields (*) of the form below and we will notify you immediately when we have verification.
If you have any questions regarding the completion of this online form or about using insurance to pay for alcohol and drug rehab, please call Toll Free: 888-267-8070

*Indicates Response Required

*Patient Full Name

*Date of Birth

*Sex

*Patient Address 1

Patient Address 2

*City

*State

*Postal Code

*Patient Phone Number

*Policy Holder Number

*Policy Holder Date of Birth (DOB)

Policy Holder Relationship

Employer

Employed

Student

*Insurance Company

*Insurance Phone Number

*Insurance Member ID

*Insurance Group ID

*Type of Plan

Your Email (required)

Additional comments


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