Nationally Recognized Treatment

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Patient Information
Patient Name**
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Patient SS NO*
Patient D.O.B* (mm/dd/yy)*
MM slash DD slash YYYY
Substance(s) Used*
Frequency, Length of use*
Detox Needed*
( Previous Treatement ) list all*
Plan Information
Insurance Provider*
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ID Number*
Group Number*
Provider Phone No*
Employer*
Subscriber Information (if different from identified patient)
Insured Name*
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TOLL FREE 1-866-888-4911

Verify your insurance.

The ability to pay should never get in the way of getting addiction help. Intervention 911 works with most major health insurance plans. To confirm your coverage, call our admissions specialists today

Insurance Verification

Patient Information

Plan Information

Subscriber Information (if different from identified patient)

Internal Use Only

TOLL FREE 1-866-888-4911

Verify your insurance.

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