Insurance Verification

Name *

Address *

City *

State *

Zip Code *

Gender

Female
Male

Phone

Social Security Number

Date of Birth

Employed?

Yes
No

Student?

Yes
No

Drug of Choice

Medical Detox Needed?

Yes
No

Name

Social Security Number

Date of Birth

Relationship to Patient

Employer

Insurance Company

Insurance Phone #

Group #

Id #

Type of Plan

Any medical conditions?

Yes
No

If yes, describe: :

Any recent injuries?

Yes
No

If yes, describe, including date:

Any recent surgeries?

Yes
No

If yes, describe, including date:

Is the patient on any medication?

Yes
No

If yes, list the names of the medications:

Any suicide attempts?

Yes
No

If yes, when?

Any suicidal ideation at present?

Any special requests?
(Example: meds the patient wants allowed as PDS)

Medical detox required?

Yes
No

if yes, date/time approved by medical director:

Contact Name

Contact's Phone Number

Contact's Email

Insurance Verification

Patient Information

Insured's Information

Insurance Company

Contact Information

HIPPA

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