Run Insurance Benefits

Person Submitting Information
Phone
email
Patient Information
Patient Name
Patient D.O.B
Patient SS Number
Substances Used
Frequency
Last Used
Detox Needed
Plan Information
Insurance Provider
ID Number
Group Number
Provider Phone No
Employer
SUBSCRIBER INFORMATION (If different from Identified Patient)
Insured Name
Insured D.O.B
Insured SS NO
City, State – Zip
INTERNAL USE ONLY
Benefits
Deductible
Co-Pay
Days Pre Auth
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