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Pre-Verify Benefits

= Required

Patient Name

First Name

Last Name

Patient Home Address

Address

City

State

Zip

DOB (MM/DD/YYYY)

Patient's Contact Information

Patient’s Home Phone

Patient’s Cell Phone

Patient’s Email Address


Insured's Name

First Name

Last Name

Insured's Home Address

Address

City

State

Zip

Insured's Contact Information

Insured's Home Phone

Insured's Cell Phone

Insured's Email Address


Insurance Information

Insured's Employer

Insured's Occupation

Insurance Provider

Insurance Plan Type
HMOPPOEPO

ID Number

Group Number

Customer Service / Substance Abuse Benefits Phone

Treatment Needs

Drugs of Choice

Have you ever been treated for addiction before?

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