Check Your Insurance Benefits Now!

Check Your Insurance Benefits

We honor many more insurance providers than listed on our website - We are often able to negotiate benefits with most insurance providers.

* Indicates required field

Insured's Name (Policy Holder) *

First

Last

Patient's Name (If different) *

First

Last

Patient's Date of Birth *

Phone / Cell *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Please provide additional comments *

Insurance Company *

Insurance Company Phone Number *

Member ID No. (include alpha-prefix) *

Group Number *

State level of care desired: *

DETOX RESIDENTIAL IOP ( Intensive Outpatient)

List substances, Prescription drugs & Amounts? *

Have you been in treatment in the last 90 days? *

Yes No

If less than 90 days state for how long *

When do you wish to admit? *

Upload front of insurance card *

Max file size: 20MB

Upload back of insurance card *

Max file size: 20MB

Name of person who filled this form *

Who referred you to us? *

SUBMIT

Call Now (310) - Hillside (310) 445-5743

Check Your Insurance Benefits Now!

We honor many more insurance providers than listed on our website - We are often able to negotiate benefits with most insurance providers.

Mark of Excellence Behavioral Health Care !!