Insurance Assessment

In order for us to ascertain insurance information, please fill out this form completely then submit. All information will remain strictly confidential and will be used for singular assessment purposes only.

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 HMO   PPO  
Insurance Company Name
Insurance Company Phone
Effective Date
Please use format MM-DD-YYYY
Intervention Specialists and our treatment professionals have no affiliation with any treatment center or facility. NYC's Intervention Specialists is not a referral service and adheres to the AISCB Code of Ethics. Intervention Specialists profits in no way from your choice of treatment facilities either directly or indirectly.