Facilities, Families, or Individuals - To obtain a Verification of Benefits, complete this form.

Patient First Name *

Patient Last Name *

Patient Date of birth *

Email Address (If Facility use facility Email) *

Todays Date

Level of Care Needed: *

TMS

Substance Abuse - IOP

Mental Health - IOP

Patient Phone Number (If Facility please place Facility Number) *

Requested Facility Name (Location Specific) *

City & State You're Located in *

Insurance Carrier Name & ID Number *

Upload Insurance Card *

Upload any Secondary Insurance Card

Upload Identification Card or Drivers License *

Additional Notes

Please Confirm *

I declare that the info I've provided is accurate & complete