Insurance Verification

REACH OUT TO US TODAY

We understand how the financial side of your decision to stay with us might be a concern. Therefore, we make the insurance verification process as straightforward as possible. Give us a call at 833.551.2304 or fill out the form below and we can help you determine what program will suit your needs and contact your insurance provider and determine your level of benefits.

Your Contact Information
Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
MM slash DD slash YYYY
Your Date Of Birth*
MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
- Yes
- No
Policy Holders Name*
First Last
Policy Holders Date Of Birth*
MM slash DD slash YYYY
Policy Holders Address**
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*
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REACH OUT TO US TODAY

Your Contact Information

Loved Ones Information

Your Information

Insurance Information

New Beginnings are Happening Every Day!

Make the choice to end chronic
addiction and relapse today.

REACH OUT TO US TODAY

Your Contact Information

Loved Ones Information

Your Information

Insurance Information

New Beginnings are Happening Every Day!

Make the choice to end chronic addiction and relapse today.

Make the choice to end chronic
addiction and relapse today.