Please complete the below insurance form and we will confirm your benefits and get back to you ASAP.
Did you purchase your policy through the Health Insurance Exchange?
Client's Date of Birth
How did you hear about us?
Are you working with an Admissions Coordinator?*
Address on File with Insurance Company
Client's Phone Number*
Recent Substance Use by Substance (How much/How Often)
Contact Person Once Verification is Complete
Best Time to Contact*