Admissions Insurance Verification Form

NOTE: All the following information is required so we can provide you with an accurate assessment. All information is securely transmitted and our email system is HIPPA compliant to ensure the security of your information.

The person entering the program.

Street, City, State / Province / Region, Zip, Postal Code, Country

If the client is covered under another parties insurance, that party would be the subscriber and their name would be used here.


Mother, Father, Husband, etc

This information can be found on the back of the card. We accept either the Provider Contact Number or Customer Service Number

Usually on the front of the card

Add the number here if there is one

So we can contact you after our evaluation.

We are a licensed residential holistic mental health and addiction treatment center, that has helped 1000's of men and women withdrawal from drug addictions over the past 11 years. We care about you and your health. By filling out this form you are asking us to check your Insurance Provider Benefits and contact you back about your insurance coverages and any other options that are available to you for treatment services.

Thank you!