Insurance
Coverage

We Accept a Variety of Insurance Policies

We accept a variety of insurance policies. We are in-network with most plans. Call us to verify your plan.

Call Admissions to Verify

Insurance
Verification

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Client Information

Child's Legal First & Last Name:*

First Last

Child's DOB*

Parents's Legal First & Last Name:*

First Last

Parent's Phone Number*

Email*

Referral Source*

Insurance Information

Insurance Company Name*

Phone*

Policy #*

Member ID*

Group #*

Subscriber Name:*

First Last

Subscriber DOB*

Photo of Front of Insurance Card*

Accepted file types: pdf, jpg, png, gif, doc, docx, Max. file size: 2 MB.

Photo of Back of Insurance Card*

Accepted file types: pdf, jpg, png, gif, doc, docx, Max. file size: 2 MB.

Do you have a secondary insurance provider?*

Yes

Secondary Insurance Information (if applicable):

Insurance Company Name*

Phone*

Policy #*

Member ID*

Group #*

Subscriber Name:*

First Last

Subscriber DOB*

Photo of Front of Insurance Card*

Accepted file types: pdf, jpg, png, gif, doc, docx, Max. file size: 2 MB.

Photo of Back of Insurance Card*

Accepted file types: pdf, jpg, png, gif, doc, docx, Max. file size: 2 MB.

Insurance Coverage

Client Information

Insurance Information

Secondary Insurance Information (if applicable):

URGENT SUPPORT AVAILABLE 24/7

Insurance
Coverage