INSURANCE | CHECK INSURANCE

If you are interested in what your insurance information will cover, you can submit your information to us prior to your assessment. Please use this web form to authorize Ashwood Recovery to check your insurance benefits on your behalf and report back to you.

 

 

*Denotes Mandatory Field

Primary Policy Holder's Name *:
Primary Policy Holder's Date of Birth *:
Potential Client's Name *:
Potential Client's Date of Birth *:
Mailing Address Listed with Insurance Carrier *:
Best Contact Number *:
Primary Insurance Carrier *:
Policy ID # *:
Group ID # *:
Insurance Company Phone Number *:
The Insurance Company Phone Number should be listed on the back of the card. Please provide the number for providers, pre-authorization, substance abuse or mental health
Secondary Insurance Carrier :
Policy ID # :
Group ID # :
Insurance Company Phone Number :
The Insurance Company Phone Number should be listed on the back of the card. Please provide the number for providers, pre-authorization, substance abuse or mental health
Reason Seeking Treatment *:
Please Describe Any History of Mental Health Diagnosis :
By clicking "submit" below you authorize Ashwood Recovery to perform an insurance verification on your behalf, in accordance with our Health Insurance Portability and Accountability Act of 1996 (HIPAA) Disclaimer and Notice of Privacy and Confidentiality