Contact Information

First Name *

Last Name *

Date Of Birth *

Email Address *

Preferred Contact Method

Location

City *

State *

Insurance Information

Insurance Company Name *

Member ID / Policy Number *

Group Number *

Insurance Phone Number

(on back of card)

Policy Holder Name *

Policy Holder Date of Birth *

Relationship to Policy Holder

Policy Number

Upload Insurance Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Your information is kept confidential and used only for insurance verification purposes. (Accepted: JPG, PNG, PDF)

OPTION 1. Please upload clear photos of both sides of your insurance card

OPTION 2. You can take a photo directly from your phone when selecting the file.

OPTION 3. If you prefer, you can submit this form without uploading your card, and we will collect it during our call.

Clinical Snapshot

What are you seeking help for?

Have you received treatment before?

Yes

When are you looking to begin?

Is there anything important you’d like us to know about your situation? (Briefly)

Financial Readiness

Are you open to private-pay options if insurance coverage is limited?

Yes

Maybe

Consent

I have read and agree to the above terms.

By typing your name below, you acknowledge that this constitutes your electronic signature and authorize Rippling Waters Men’s Retreat & Recovery Center to contact you and to obtain and release information with your insurance provider as needed to review potential out-of-network benefits and reimbursement options.

Full Name *

Date *

Electronic Signature

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