Verify Your Recovery Insurance Benefits

Enrollee's Information

Please provide the information requested.
We will verify your benefits and contact you within 3 hours to discuss your treatment options.

First Name (required)

Last Name (required)

Phone Number (required)

email (required)

Date of Birth (required)

Social Security #Social Security # (required)

Policy Holder Information (if different from person in need of treatment)
I am the Policy Holder yesno

First Name

Last Name

RelationshipSelect OneDaughterSonSpouseDomestic PartnerOther Dependant

Date of Birth

Social Security Number (numbers only)

Policy (Billing) Address

Policy (Billing) City

State

Policy(Billing) Zip

Policy Information

Insurance Company Name (required)

Policy Number (required)

Policy Group Number (require)

Provider Phone Number (typically on back of membership card)

Secondary Policy Information

I have a secondary policy noyes

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