Client facing Insurance Verification Request Form

Insurance Verification Request Form
Client & Contact Info
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Phone Number
Please enter a valid phone number.
Email
example@example.com
Who is filling this out? (Self / Parent / Case Manager / Other)
Insurance Information
Primary Insurance
Member ID
Group Number
Policyholder's Name
Policyholder's DOB
Upload a photo of your insurance card (front & back)

Cancelof
Treatment Interest
What level of care or services are you seeking?

3.5 Womens Residential Substance Use Services2.1 Intensive Outpatient Substance Use Services1.0 Outpatient Substance Use Services2.1 + Board and LodgingMental Health Services
Are you looking to use your insurance benefits for coverage?

YesNo /Self Pay
Authorization
Please review and check below to give us permission to verify your insurance benefits:

Yes, I give Recovering Hope permission to contact my insurance provider to verify my mental health and substance use treatment coverage.
Before you submit:
You’ll be directed to complete a Release of Information (ROI). This allows us to communicate with your insurance company to verify your coverage.
Should be Empty:

Insurance Verification Request Form