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Verify Insurance

Midwest Recovery Centers Insurance Verification Form

Midwest Recovery Centers works with most major insurance companies to help you offset the costs associated with our treatment program.

Complete this form to see what portion of our services are covered by your health insurance company.

General Information
Who Is This For?*
Patient Full Name
First Last
Patient Date of Birth*
Patient Social Security #
Subscriber Full Name
Subscriber Date of Birth
Subscriber Social Security #
Email*
Home/Cell Phone Number*
How did you hear about us?*
Address
Address on file with your insurance carrier.
Street Address*
City*
State*
Zipcode*
Insurance Information
Insurance Carrier*
Insurance ID #
Provider Services Phone # (on back of card)*
Group ID #
Type of Plan
- PPO
- HMO
- EPO
- POS
- Unknown
Is this a COBRA Policy?
- Yes
- No
- Unknown
Photo Upload: FRONT of Insurance Card (optional)
Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
Photo Upload: BACK of Insurance Card (optional)
Max. file size: 50 MB.
Additional Information
Have You Been to Treatment Before?
Brief Description of Your Problem
Comments
When and how is the best way to contact you?
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Verify Insurance

Midwest Recovery Centers Insurance Verification Form

General Information

Address

Insurance Information

Additional Information