Verify Your Insurance Benefits

Please fill out the form below, or you may call (877) 308-8338 to speak with our Admissions staff.

Today's Date:*
Referred by:
Phone:
Patient Information
Patient's Full Name:*
SS#:*
Age:
DOB:*
MM
DD
YYYY
Gender:*
- Male
- Female
Driver's License No.:
State Issued:
Marital Status:
Patient's Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient's Phone:
Patient's Cell Phone:
Patient's Email:
Emergency Contact:*
Relationship:*
Phone:*
Policy Holder Information
Full Name of Policy Holder:*
Policy Holder SS#:*
Policy Holder DOB:*
MM
DD
YYYY
Policy Holder Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy Holder Phone:*
Policy Holder Email:*
Policy Holder Primary Ins. Co.:*
Primary Ins. Policy ID#:*
Primary Ins. Group #:
Ins. Company Phone:*
Other Ins. Company:
Other Ins. Policy ID#:
Other Ins. Group #:
Other Ins. Phone:
Patient History
Known Issues:*
Previous Treatment (use + to add more rows):
Where When Why
Previous Detention, Incarceration or Probation (use + to add more rows):
Where When Why Contact Name Number
Case Manager, Interventionist, and Current Physician
Case Manager/Interventionist:
Phone:
Email:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Physician:
Phone:
Email:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Routine Medications (use+ to add more rows)
Medication Current Rx# Dosage Reason Start/End Physician
Person Completing This Form
Your Name:*
Relationship:*
Your Phone:*
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Verify Your Insurance Benefits

Patient Information

Policy Holder Information

Patient History

Case Manager, Interventionist, and Current Physician

Person Completing This Form