Insurance Benefits

Entering detox and rehab can be a life-saving decision, and your financial situation should not hold you back from seeking the care you need for yourself or a loved one.

To make detox more accessible and affordable for all those struggling with a substance misuse disorder, Ken Seeley Communities works with most major health insurance providers. Call us toll-free at 866-888-4911 to verify your insurance coverage with our admissions specialists and ask any questions you have about using your medical insurance to cover your treatment.

Name

Email Address*

Phone Number*

PATIENT INFORMATION

Patient Name*

Patient D.O.B* (m/d/yy)

Patient SS NO

Substance(s) Used

Frequency, Length of use

Detox Needed

Previous Treatement )list all)

PLAN INFORMATION

Insurance Provider

Plan Type

ID Number

Group Number

Provider Phone No

Employer

SUBSCRIBER INFORMATION (If different from Identified Patient)

Insured Name

Insured D.O.B (mm/dd/yyyy)

Insured SS NO

City

State

Zip

INTERNAL USE ONLY

Benefits

Deductible

Co-Pay

Days Pre Auth

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Security Code