Verify Insurance

VERIFY INSURANCE
  • Insurance Information
  • Insurance Name*
  • Insurance Phone #*
  • Policy Holder*Full Name
  • Policy Holders*Phone Number
  • Member ID #*
  • Group #*
  • Patient's Information
  • Patient's Full Name*
  • Patient's DOB*Date of birth
  • Policy holder DOB*Date of birth
  • Patient's Address*on File w/ Insurance Company
  • Patient's Phone #*
  • Presenting Substance*
  • Date of last use*
  • Amount of Time You Have Consumed Substance*
  • Have You Been To Treatment In The Last Year*
  • Amount of use*per day