Insurance Benefits

Fill out information below to find out if you qualify.

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