TW Insurance Verification Form

Verify Insurance Benefits Online
Submitting your insurance information on our HIPAA Compliant Form will allow our Admissions Department to complete a verification of benefits of your insurance coverage which we can then review with you.

Please note: We are not contracted (in-network) with any insurance companies and therefore do not accept HMO policies; all policies must have out of network benefits in order for our Residential Treatment Center to work with your policy. Also, please understand that we do NOT accept Medicaid or Medicare.
Contact Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Relationship to Patient*
Insurance Policy Information
Patient Name*

First NameLast Name
Patient Birthdate*
Insurance Company*
Insurance Phone Number*

Area CodePhone Number
Member ID Number*
Policy Number
Group Number*
Policy Holder Name*

First NameLast Name
Policy Holder Birthday*

MonthDayYear
Date
Policy Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Phone Number*

Area CodePhone Number
Upload Front and Back of Insurance Card

Upload Files
File Format: PDF, JPG, JPEG, PNG Cancelof
Date

MonthDayYear
Date
Please verify that you are human*
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Verify Insurance Benefits Online