Username:
Password:
Fields marked with a "
*
" are required to check for coverage
YOUR INFORMATION (not necessarily the prospective patient)
Name:
Email:
Address:
City:
State:
Zip:
Telephone-Home:
Business:
Relation:
PROSPECTIVE PATIENT
*
Name:
*
Address:
*
City:
*
State:
*
Zip:
*
Telephone-Home:
Business:
*
Date of Birth:
*
Social Security #:
Comments:
Please let us know of any special circumstances and how we should contact you and/or the prospective patient.
INSURANCE COMPANY
*
Insurance Company:
*
Insurance Phone #:
*
Policy #:
*
Insurance Group #:
Plan:
Effective Date:
INSURED PARTY
*
Insured Name:
*
Relation to Patient:
*
Social Security #:
*
Date of Birth:
*
Employer:
Still Employed?
Yes
No
Length:
Term Date:
I am providing this information for use by Treatment Solutions only. Any information given be kept private and confidential.
954 832 9130
