Verify Your Insurance

Check Your Policy Coverage By Filling Out This Confidential Form Below

Contact Information
Who should we contact after verification?
Name*
First Last
Phone*
Email*
Insurance Information
Primary's Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Patient's Name*
First Last
Primary Date Of Birth*
Patient Date Of Birth*
Insurance Provider*
Member ID*
Group ID Number*
Insurance Phone Number
Comments
Front Of Insurance Card*
Back Of Insurance Card*
By submitting this form, I agree to be contacted by Peaks Recovery Centers. Our admissions director will contact you shortly to discuss your recovery options. All information shared with us is completely confidential. See our HIPAA Privacy Policy.