PPC Insurance Verification Form

(888) 235-3003

Find Out if Your Insurance Covers Treatment Today

Take the first step toward recovery. Verify your insurance benefits quickly, confidentially, and with no obligation.

Our admissions team works directly with most insurance carriers to confirm coverage for detox, inpatient, outpatient, and dual-diagnosis programs.
Fill out the form below to discover what treatment options your insurance benefits can make possible.

"*" indicates required fields

Patient Name:*

First Last

Patient Phone Number:*

Point of Contact (who should we call back if NOT Patient Name above) :

Point of Contact Phone Number:

Patient Date Of Birth:*

Email Address:*

Primary Insured Address:*

Street Address Address Line 2 City State ZIP Code

Primary Insured Name:*

Primary Insured Phone Number:*

Primary Insured Date Of Birth:*

Insurance Company Name:*

Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*

ID #:*

Group #:*

Will the patient be getting FMLA Leave while in treatment?*

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

How did you hear about us?*

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(888) 235-3003

Find Out if Your Insurance Covers Treatment Today

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