Insurance Verification

All information shared is protected by HIPPA and kept confidential. We do not share any information outside our organization.

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Insurance Company(Required)

Member ID(Required)

Insurance Type(Required)

PPO

HMO

Private Pay

Date of Birth(Required)

MM slash DD slash YYYY

Treatment For(Required)

Myself

A Love One

Preferred Program(Required)

Detox

Residential Treatment

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Certified by the Department of Healthcare Services.
Certification #: 300436AP; Expiration Date: 03/31/2026 gg super modz patched