Insurance Coverage Form

Use the following secure form to send us information about your insurance coverage. Note: Fields marked with an asterisk are required to verify coverage.

List of the In Network Insurance Plans please follow this link.

YOUR INFORMATION (not necessarily the prospective patient)

*Name:
*Email:
Address:
City:		State:	Zip:
Telephone – Home:	Business:
Relation:

PROSPECTIVE PATIENT

*Name:
*Address:
*City:		*State:		*ZIP:
*Telephone – Home:			Business:
*Date of Birth:
*Social Security #:
Comments:
	Please let us know about any special circumstances and how we should contact you and/or the prospective patient.

INSURANCE COMPANY

*Insurance Company:

*Insurance Phone #:
*Insurance Policy #:
*Insurance Group #:
Plan:
Effective Date:

INSURED PARTY

*Insured Name:
*Relation to Patient:
*Social Security #:
*Date of Birth:
*Employer:
Still Employed?	Length:
Term Date:

I am providing this information for use only by A Bridge to Recovery. Any information given will be kept private and confidential.

Services

Insurance Coverage Form