Insurance Verification- Harmony Recovery

1
Client Name:* This field is required.
First Name
Last Name
2
Mobile Phone #* This field is required.
3
E-mail Address* This field is required.
example@example.com
4
Birth Date* This field is required.
Month
Day
Year
5
Insurance Company* This field is required.We Do Not Accept Medicaid or Medicare
Provider Name (Blue Cross, Aetna, etc...)
6
Member / Subscriber ID#* This field is required.
Located on your insurance card
7
Insurance Company Phone #* This field is required.
Typically located on the back of your insurance card
8
What Are You Seeking Treatment For?* This field is required.You Can Select Both If They Apply To You
Substance Use
Mental Health
9
Consent* This field is required.
I agree to receive Phone Calls and SMS text messages from Harmony in order to discuss my treatment options. My information will remain private and I may opt out at any time by replying STOP.
Should be Empty: