Insurance Verification Form - The Heights Treatment

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1 Personal Information

2 Insurance Information

3 Verification

Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Male
- Female
Date of Birth*
MM
DD
YYYY

Primary Insured Name*
First Last
Primary Insured Email*
Primary Insured Phone*
Primary Insured Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insured Gender*
- Male
- Female
Primary Insured DOB*
MM
DD
YYYY
Insurance Company Name*
Insurance Phone
ID #*
Group #
Plan Type*
- PPO
- HMO
- EPO
- Unsure
Additional Details

All information submitted is kept 100% confidential in accordance with federal HIPAA mandates. Upon submission this information will be sent to our health insurance authorization team for immediate processing...
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