Verify My Insurance

Taking the first step towards change is the biggest challenge, but the results are more than rewarding. Contact us today, and our experienced admissions coordinators will make the process of getting help easy.

Below is our insurance verification form. With so many insurance providers and policies, this form will make verifying your insurance benefits much easier. Once you fill out this form and submit it, our admissions coordinators will be able to check your individual policy to see what your specific insurance coverage looks like. Alternatively, you can always call us directly in order for us to verify your insurance.

"*" indicates required fields

Name*

First Last

Phone*

Email*

Date of Birth*

Address*

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

Insurance Company*

Plan Type(HMO,PPO)*

Name on Card*

Member ID*

Insurance Phone*

Group ID*

Social Security #*

Alcohol Consumption?*

Drug Use?(Please List)*

Health Issues?*

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