Insurance Verification


Submit your health insurance information for verification. All information is held confidential. Fill in all required fields (*) of the form below and we will notify you immediately when we have verification. If you have any questions regarding the completion of this online form or about using insurance to pay for alcohol and drug rehab, please call Toll Free: (877) 405-9411

You may also print and fax the form.

*Indicates Response Required

*Patient Full Name

*Date of Birth

*Sex

*Patient Address 1

Patient Address 2

*City

*State

*Postal Code

*Patient Phone Number

*Policy Holder Number

*Policy Holder Date of Birth (DOB)

*Policy Holder Relationship

*Employer

Employed

Student

*Insurance Company

*Insurance Phone Number

*Insurance Member ID

*Insurance Group ID

*Type of Plan

Your Email (required)

Additional comments

How did you hear about PACE

*Name of person submitting the form

*Contact number for person submitting the form

Contact Us

...