Insurance Verification Form

Don’t let financial reasons stop you from seeking the help you need. At Sober Living Orange County, it is our goal to provide you with quality care at a price you and your family can afford. Please fill in the form and submit it for review. We’ll check your coverage as soon as possible and have a StepHouse Recovery intake specialist call you and explain what your options are.

*All information is confidential and will not be shared with third parties. 

Patient Information

 

Your Full Name *

D.O.B. *

Sex

Social Security Number

Subscriber Name *

Contact Information

 

Phone Number *

Your Email *

Address

 

Street Address *

City *

State *

Zip Code *

Insurance Information

 

Insurance Company *

Insurance Phone Nunmber

Subscriber's Name *

Subscriber's D.O.B

Subscriber's Social Security Number

Subscriber's Phone Number

ID Number

Group Number *

Plan Type

Address

10537 Slater Avenue
Fountain Valley, CA 92708

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