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Insurance Verification

* = required fields  

Insurance Information

Patient’s Last Name: * 
Patient’s First Name: * Patient’s Middle Name: *
Patients Sex:*
Male  
Female
Patient’s Email Address: * 
Patient’s Date of Birth:*
(mm/dd/yy)
Patient’s Phone #: *
( ) -
Patient’s Cell #:
( ) -
Name of Insured Person: *
Relationship to patient: *
Insured’s Date of Birth: *
(mm/dd/yy)
Insured’s Phone#:*
( ) -
     
Yes, I am the patient.  My address (city, state and zip) is: *
No, I am not the patient.  My address (city, state and zip)  is:
  (If not the patient, complete the patient’s address below) 
Patient’s address (city, state, and zip) is:
Insured’s Employer:* Name of Insurance:* Insurance Phone #: *
( ) -
Insured Employer Phone #: *
( ) -
Group Name:
Policy /ID #: * Group#: *
Name of Person who referred the patient: *
Phone Number of Person Who Referred Patient: *
Patient's Substance Abuse History: *