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

Get Social

Address

10537 Slater Avenue
Fountain Valley, CA 92708

StepHouse Recovery

Learn More
Copyright © Sober Living Orange County 2017