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?


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?*


Address on File with Insurance Company


Client's Phone Number*

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

Treatment History

Contact Person Once Verification is Complete


Phone Number*


Best Time to Contact*