Your Name

Your Phone Number

Your Email

Client Name (if different from above) *

Insured Name (if not client)

Client Email (if different from above) *

Client Phone Number (if different from above) *

Client Date of Birth *

Address (Line One) *

Address (Line Two) *

City *

State *

Zip Code *

Insurance Company *

Insurance Company Address (Line One) *

Insurance Company Address (Line Two) *

Insurance Company City *

Insurance Company State *

Insurance Company Zip Code *

Insurance Company Phone Number *

Health Plan ID # *

Group # *

Treatment Level *

Residential Treatment Programming

Partial Hospitalization Programming

Intensive Outpatient Programming

Don't Know / Unsure

Program Location * Program Location

Do you have a student insurance policy? *

Yes

No

Don't Know / Unsure

Do you have a secondary insurance policy?

Yes

No

Don't Know / Unsure

Are you currently on a Cobra policy?

Yes

No

Don't Know / Unsure

How did you hear about us? *

Please upload a photo of the front and back of your insurance card

Drop a file here or click to upload Choose File

Maximum upload size: 134.22MB

Insurance Verification