Insurance Verification

Ensuring that your insurance coverage is accurate and up-to-date is crucial for a seamless experience. We understand the importance of transparency and efficiency in managing insurance information, which is why we’ve designed this simple and secure verification process. By completing this form, you can ensure that we have the most accurate details about your insurance coverage, facilitating smooth transactions and minimizing any potential disruptions in your recovery journey.

Please fill out the form below, and we will be in touch with you shortly. Thank you.

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Patient Name:*

First Last

Patient Phone Number:*

Point of Contact (who should we call back if NOT Patient Name above) :

Point of Contact Phone Number:

Patient Date Of Birth:*

Email Address:*

Primary Insured Address:*

Street Address Address Line 2 City State ZIP Code

Primary Insured Name:*

Primary Insured Phone Number:*

Primary Insured Date Of Birth:*

Insurance Company Name:*

Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*

ID #:*

Group #:*

Will the patient be getting FMLA Leave while in treatment?*

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

How did you hear about us?*

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Should you have any questions or require assistance with completing the Insurance Verification Form, please don’t hesitate to reach out to our friendly team. We’re here to help ensure that your insurance information is accurate and that you receive the quality care you deserve.

Most Insurance Accepted

VA Community Care Network Insurance accepted for drug and alcohol treatment

Optum health insurance accepted for drug and alcohol treatment

Insurance Verification Form

Insurance Verification

Most Insurance Accepted

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