Insurance Verification

Who is seeking treatment?(Required)

Yourself

Someone Else

YOUR INFORMATION

Your Name(Required)

First Last

Your Email(Required)

Your Phone Number(Required)

Your Date of Birth(Required)

INSURANCE INFORMATION

Policy Holders Name(Required)

First Last

Policy Holders Date of Birth

Policy Holders Address

Street Address Address Line 2 City State ZIP Code

Insurance Company's Name(Required)

Insurance Company's Phone Number

Member ID(Required)

Group Number

Subscriber relationship to client(Required)

Additional Comments

Please let us know any other details or information that would be helpful

Your information is confidential. Upon submission, an admissions representative will contact your insurance carrier to see what benefits are available to cover your treatment. Our admissions representative will also contact you via phone to gather basic information and conduct an initial assessment. For more information, see Admissions.