Verify Benefits

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Verify Your Benefits

Fill out the form below to verify your benefits, and one of our team members will contact you as soon as possible.

POINT OF CONTACT

Name(Required)

First Last

Phone(Required)

Email(Required)

PATIENT INFORMATION

Desired Level of Care(Required)

Residential / Inpatient

Detox

Best Time to Contact(Required)

Morning

Evening

Patient Name(Required)

First Last

Patient Phone(Required)

Patient Email(Required)

Patient Date of Birth(Required)

Patient Sex(Required)

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INSURANCE INFORMATION

Primary Insured Full Name(Required)

First Last

Primary Insured Phone Number(Required)

Primary Insured Date of Birth(Required)

Primary Insured Street Address

Same As Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Company(Required)

Policy Number(Required)

Policy Group Number(Required)

This field is hidden when viewing the form

Employer Sponsored Plan(Required)

Employer Sponsored Plan

PRIOR TREATMENT

Please list all treatment centers, therapists, psychiatrists or referring doctors you've attended in the previous 12 months.

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Verify Benefits

Verify Your Benefits

POINT OF CONTACT

PATIENT INFORMATION

INSURANCE INFORMATION

PRIOR TREATMENT

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