Check Your Coverage and Start Your Healing Journey

Your well-being is our priority. By completing this form, our team can verify your benefits and make sure you receive the care you need with the best coverage available.

First Name

Last Name

Date of Birth

Primary Substance Abused

Are you seeking treatment for yourself, or on behalf of someone else?

Myself Someone else

Phone Number

Your Email

Insurance Information
Please provide as much of your insurance plan information as possible. We will need to speak with you in order to fully verify your coverage.

Insurance Provider

Insurance ID Number

Insurance Group Number

Insurance Phone Number

Additional information

Person Needing Treatment

Fill out the information below regarding the individual needing drug and alcohol rehab services.

Verify Insurance

Check Your Coverage and Start Your Healing Journey

Person Needing Treatment

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