INSURANCE

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)

1. *Name:
2. *Email:
3. Address:
4. City:
5. State:
6. Zip:
7. Telephone –Home:
8. Relation:

PROSPECTIVE PATIENT

1. *Name:
2. *Address:
3. *City:
4. *State:
5. *ZIP:
6. *Telephone–Home:
7. Business:
8. *Date of Birth:
9. *Social Security #:
10. Comments:
11. Please let us know about any special circumstances and how we should contact you and/or the prospective patient.

INSURANCE COMPANY

1. *Insurance Company:
2. *Insurance Phone #:
3. *Insurance Policy #:
4. *Insurance Group #:
5. Plan:
6. Effective Date:

INSURED PARTY

1. *Insured Name:
2. *Relation to Patient:
3. *Social Security #:
4. *Date of Birth:
5. *Employer:
6. Still Employed?YesNo
7. Length:
8. Term Date:
9. I am providing this information for use only by A Bridge to Recovery. Any information given will be kept private and confidential.

Download Forms

Downloading and completing the following forms saves time when you visit our office. Email us at admin@abridgetorecovery.com if you have problems finding the form you need.

The following forms are in Adobe PDF format. Click the Adobe icon to download the latest free version of Adobe Reader.

> Complete Intake Packet
> Consent to Release Information