Confidential Insurance Benefits Verification Form

First Name *

Last Name *

Email Address *

Phone *

Address *

City *

State *

Zip *

Date of Birth *

Are you the Primary Policy Holder for this insurance policy?

Yes

No

How would you like to get your Insurance Card to us?

I'll take/upload a picture of my card.

I'll enter my card info below

Briefly describe what substances you're struggling with and if you've ever been in treatment before. You can also use this area to add any additional information/questions that you may have for our team.