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:

Your Name (required)

Your Last Name (required)

Name of Insured (If Different Than Above)

Your Name

Your Last Name

Date of Birth of Person Seeking Treatment

MM / DD / YEAR

Phone Number (required)

Address, City, State, Zipcode

Insurance Carrier

Type of Plan
 PPO HMO

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.

Your Message