Insurance Verification Form Please fill out the form below, and we will be in touch with you shortly. Thank you. How Did You Hear About Us?Patient Name:* First Last Patient Phone Number:*Point of Contact (who should we call back if NOT Patient Name above) :Patient Date Of Birth:* MM DD YYYY Email Address:* Address of Insurance Policy HolderAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Insured Name:*Primary Insured Phone Number:*Primary Insured Date Of Birth:* MM DD YYYY Insurance Company Name:*Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*ID #:*Group #:*Have you been to any other substance abuse treatment?YesNoWhen did you go to treatment?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 work weeks 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.