Drug Rehab Insurance Check for Admissions to Ohana Recovery

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All treatment inquiries and personal information is always kept confidential.

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Confidential Insurance Benefits Verification Form

Please fill-out this brief information form in case we need to contact you about your insurance information below. Rest assured that all information shared with us is confidential.

First Name*

Last Name*

Email Address*

Phone Number*

Address*

Address 2

City*

Zip Code*

DOB*

Are you the Primary Policy Holder for this insurance policy?

Yes

Insurance Card Provider*

Member ID #*

Customer Service Phone # (Back of Card)*

Briefly describe what substances you're struggling with and if you've ever been in treatment before. You can also use this area to add any additional information/questions that you may have for our team.

Message*

0 / 150

After pressing the submit button below, please wait up to one minute for your insurance data to be securely transmitted.

Confidential Insurance Benefits Verification Form

DOB*

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