Please complete the below insurance form and we will confirm your benefits and get back to you ASAP.

Insurance Company*

Group Number

Did you purchase your policy through the Health Insurance Exchange?

YesNo

Policy Number

Insurance Number

Insurance Name*


Insured Date

Insured SSN

Client's Name*


Client's Age

Client's SSN

Client's Date of Birth

How did you hear about us?

Are you working with an Admissions Coordinator?*

YesNo


Address on File with Insurance Company

Address

Client's Phone Number*

Recent Substance Use by Substance
(How much/How Often)

Treatment History

Contact Person Once Verification is Complete

Name*


Phone Number*

Email*

Best Time to Contact*