Insurance Verification Form

Please use this page to verify your insurance.
Patient First Name:
Patient Last Name:
Patient Date of Birth:
Presenting Problem:
Alcohol Illicit Drugs
Over the Counter Drugs
Prescription Drugs
PTSD Anxiety Depression
Other:
Subscriber First Name:
Subscriber Last Name:
Subscriber Date of Birth:
I am the Subscriber
Yes No
Who are you?
Who are you seeking treatment for?
Email:
Phone Number:
Insurance Provider Name:
Insurance ID/Policy Number:
Group ID Number:
Insurance Type
Insurance Provider Phone Number: