Financial Questions

WE CAN HELP

We are able to work with all major insurance companies and help reduce the financial stressors of seeking treatment. If you provide us with your policy information, we will determine the benefits available to you for our different treatment facilities and levels of care. Our entire team works diligently to obtain the maximum benefit available from the insurance carrier.

We also accept credit cards, cashier’s checks, and wire transfers as payment for treatment. Don’t hesitate to call our toll-free number if you have questions. Our team is ready to help.


                        
                            BENEFIT VERIFICATION FORM
                            
                        

                        Name of Subscriber(Required) 
Date of birth of subscriber(Required)
                            
                            MM slash DD slash YYYY
                        
                        
Person Completing Form(Required) 
(if different than Subscriber)
Relationship to Client(Required) 
Email Address to Best Reach You(Required) 
Name of patient(Required) 
Date of birth of patient(Required)
                            
                            MM slash DD slash YYYY
                        
                        
Address on file with insurance company with subscriber(Required) 
(Full street address, city, state, and zip code)*
Phone Number(Required) 
Insurance carrier/company(Required) 
Insurance ID Card(Required) 
Provider services or pre cert phone number on back of card(Required) 
Individual or group plan? 
If group plan, group # 
Upload photo of your INSURANCE ID card (Front End)Max. file size: 100 MB.
Upload photo of your INSURANCE ID card (Back End)Max. file size: 100 MB.

We Are Here To Help

“HI MY NAME IS HENRY, AND I’M THE HEAD OF BALANCE TREATMENT CENTER’S HELP-DESK

WE CAN HELP

BENEFIT VERIFICATION FORM