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Verify Your Insurance

If you have health insurance, please enter your information below to allow us to do a free verification of benefits to determine your out-of-pocket costs for your stay. ALL INFORMATION YOU SUBMIT IS CONFIDENTIAL:

Name of Person Seeking Treatment*
First Last
Name of Insured (If Different Than Above)
First Name Last Name
Date of Birth of Person Seeking Treatment*
MM
DD
YYYY
Email
Phone
Address, City, State, Zipcode
Insurance Carrier
Type of Plan
Insurance ID#
Phone Number on Back of Card, Marked "Provider" or "Mental Health"
If this is through an employer, please indicate the name of the employer.
Comments / Brief Description of the Issue

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