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Methadone Addiction
Mental Disorders

Alcohol Addiction
Opiate Addiction

Cocaine Addiction
Heroin Addiction

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Addictions
Mental Disorders

Insurance Verification Form

"*" indicates required fields

REFERRAL CONTACT

Referral name*

Agency*

Phone*

Email*

Reason for referral?

PATIENT INFORMATION

Name*

SSN

Address*

Street Address City State ZIP Code

DOB*

Month

Day

Year

Phone*

Presenting factor for treatment now*

Substances Currently Being Abused*

Heroin

Synthetic opioids

Cocaine

Alcohol

Other

Specify what other*

Amount being used*

How Often?*

Route of Admin*

How Long?*

Last Used?*

Step Down from Detoxification*

Yes

No

If Yes, where?*

If Yes, where?*

Detox Needed?*

Yes

No

Prior Substance Abuse Treatment:*

Yes

No

Where*

What type*

When*

Outcome*

Type of Discharge*

Mental Health History?*

No

Yes

If yes please describe*

Legal Issues: (past or current)

FINANCIAL INFORMATION

Can individual/family meet financial requirements of treatment?*

No

Yes

How?*

Cash payment

Insurance

PERSON RESPONSIBLE FOR PAYMENT

Name*

Phone*

Relationship*

Primary Holder*

Relationship*

Policy Number*

Member ID*

Insurance Verified

Yes

Co-Pay

Co-Pay

Comments

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1125 Strong Road, Quincy, FL 32351
(888) 782-3342
[email protected]
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1125 Strong Road, Quincy, FL 32351
(888) 782-3342
[email protected]
Privacy Policy
Terms & Conditions

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