Insurance Verification

Our Programs & Activities Will Guide Your Teen Through Rehab

Insurance Verification

Our counselors are standing by to check your insurance. Please fill out the form here or call us at 877.466.0620 if you’d like us to verify your insurance over the phone.

Patient Information

Name (Required)

First

Last

Patient Address (Required)

Street Address

Address Line 2

City

ZIP / Postal Code

State / Province / Region

Country

Patient Address (Required)

Patient Last Four SSN (Required)

Patient Date of Birth (Required)

Primary Insured Information

Primary Insured Full Name

First

Last

Primary Insured DOB (Required)

Primary Insured Last Four SSN (Required)

Primary Insured Phone Number (Required)

Primary Insured Email Address (Required)

INSURANCE COMPANY INFORMATION

Insurance Provider Name (Required)

First

Insurance ID Number (Required)

Last

Insurance Group Number (Required)

Insurance Company Phone # (Required)

Insurance Type (Required)

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Application

Our Programs & Activities Will Guide Your Teen Through Rehab