Using Health Insurance for Treatment

Patient Name *

Policy Holder Name *

Patient Date of Birth *

Patient Mailing Address *

Name of Insurance Company *

Insurance ID# *

Insurance Group # *

Contact Number (for providers to call) for Insurance Company *

Have you had prior treament in the past? (If yes, when was your last treatment. If possible, list the programs you have attended...)

Contact Person's Name *

Contact Person's Phone *

Contact Person's Email Address *