Insurance Verification Form

Patient Name:*
First Last
Patient Phone Number:*
Point of Contact (who should we call back if NOT Patient Name above) :
Point of Contact Phone Number:
Patient Date Of Birth:*
Month
Day
Year
Email Address:*
Primary Insured Address:*
Street Address Address Line 2 City State ZIP Code
Primary Insured Name:*
Primary Insured Phone Number:*
Primary Insured Date Of Birth:*
Month
Day
Year
Insurance Company Name:*
Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*
ID #:*
Group #:*
Will the patient be getting FMLA Leave while in treatment?*

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.