Residential Treatment Centers - At Risk Youth Programs

Verify Insurance Benefits Online
Submitting your insurance information on our HIPAA Compliant Form will allow our Admissions Department to complete a verification of benefits of your insurance coverage which we can then review with you.

Please note: We are not contracted (in-network) with any insurance companies and therefore do not accept HMO policies; all policies must have out of network benefits in order for our Residential Treatment Center to work with your policy. Also, please understand that we do NOT accept Medicaid or Medicare.
Contact Information
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Relationship to Patient *
Insurance Policy Information
Patient Name *

First Name Last Name
Patient Date of Birth *
Policy Holder Name *

First Name Last Name
Insurance Company *
Insurance Phone Number *

Area Code Phone Number
Member ID Number *
Policy Number
Group Number *
Insurance Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Upload Front and Back of Insurance Card

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At Risk Youth Residential Treatment Information

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