Rehab Insurance Verification Form

Are you ready to begin the next chapter of your life free of drugs and alcohol? If so, please use our convenient form below to verify your insurance or by calling 855-626-0800 to contact our admissions team today!

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Your Contact Information
Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
MM slash DD slash YYYY
Your Date Of Birth*
MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
- Yes
- No
Policy Holders Name*
First Last
Policy Holders Date Of Birth*
MM slash DD slash YYYY
Policy Holders Address**
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*

Rehab Insurance Verification Form

Your Contact Information

Loved Ones Information

Your Information

Insurance Information

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