Intervention Specialist



Insurance Assessment

In order for us to help our clients ascertain insurance coverage, please fill out this form completely then submit. All information will remain strictly confidential and will be used for singular assessment purposes only. We do not accept insurance and our coverage assessment is not a guarantee of coverage. Most policies base coverage on “Medical Necessity”, which means in real terms that insurance providers can, and do cut coverage, often and with negative consequences.

Client Full Legal Name
Client Date of Birth

Please use format MM-DD-YYYY
Insured Name
Insured Date of Birth

Please use format MM-DD-YYYY
Insured Address
City
State

Your state's 2-letter abbreviation.
Zip

Your 5 digit zip.
Billing Home Phone

Will not call - For verification only
Insured SS# or ID
Group #
Insurance Type
Insurance Company Name
Insurance Company Phone
Effective Date

Please use format MM-DD-YYYY