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Insurance Verification

Fill out the form below for a FREE insurance verification to see if you are covered for our drug and alcohol treatment services.

Applicant Info
First Name*
Last Name*
Phone Number
Patient Info
First Name*
Last Name*
Date of birth*
Subscriber First Name
Subscriber Last Name
Date of birth
Insurance Info
Insurance Name
Policy Number or Member ID Number
Group Number
Insurance Phone Number
Upload
Insurance Card (front side)
Maximum file size: 10 MB
Driver License or State ID Card (front side)
Maximum file size: 10 MB
Insurance Card (back side)
Maximum file size: 10 MB
Driver License Or State ID Card (back side)
Maximum file size: 10 MB