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 Use Facility Number) *

Facility Name (Location Specific)

City/ST *

Insurance Carrier Name & ID Number

Upload Insurance Card

Additional Notes

Please Confirm *

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