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 (714) 274-9239 or Toll Free: (877) 405-9411
You may also print and fax the form.