Verify Your Insurance

Drug & Alcohol Addiction Treatment in Midway, Utah

If you have your insurance information and want us to verify it quickly, please fill out the entire form and click submit. We will contact you via phone or email as soon as we have checked on your policy. Thank you for taking that next step through insurance verification. Learn more about our addiction therapy services and substance abuse treatment programs today.

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YOUR CONTACT INFORMATION

First Name*

Last Name*

Return Callback Phone Number*

Email*

Who is Seeking Treatment?

Yourself

A Loved One

How Did You Hear About Us?

YOUR INFORMATION

Your Date of Birth

Additional Information About Loved One

LOVED ONES INFORMATION

First Name

Last Name

Loved Ones Date Of Birth

Additional Information

INSURANCE INFORMATION

Would you like us to verify your or a loved ones insurance benefits?

Yes

Policy Holders Name

First Name

Last Name

Policy Holders Date Of Birth

Policy Holders Address

Country

Address Line 1*

Address Line 2

City*

State*

ZIP Code*

Insurance Company's Name

Insurance Company Phone Number

Member ID

Group Number

Subscriber Relationship To Client

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