Insurance Verification for Chapter 5 Recovery

Complete the form below to begin our admission process.

Patient Information

Patient First Name
Patient Last Name
Patient Email
Patient Telephone
Patient DOB
Patient Social Security #
Patient Address 1
Patient Address 2
Patient City
Patient State
Patient Zip Code

Policy Holder Information

  Check This Box If You Are The Policy Holder

Policy Holder First Name
Policy Holder Last Name
Policy Holder Relationship
Policy Holder Email
Policy Holder Telephone
Policy Holder DOB
Policy Holder Social Security #
Policy Holder Address 1
Policy Holder Address 2
Policy Holder City
Policy Holder State
Policy Holder Zip Code

Policy Information

Insurance Company
Insurance Company Telephone (Back of Card)
Policy/Member Number
Group ID
Plan Type
Additional Comments
In accordance with HIPPA and your rights to how your private health information is handled, by submitting the above information, you are authorizing Royal Life Centers to contact you via the method you supplied. During normal business hours, we can usually verify your benefits in about an hour. However during hours aside from normal business hours, we will be able to verify your benefits first thing the following morning and return your request for help. The information you provided above will be used by our Admissions Department to assist you with all of your options while seeking treatment. We are fully committed to your privacy and confidentiality. Your information will not be used for any other purpose other than to help you find treatment and your information will not be shared with any third parties.

Thank you!

Your insurance information has been sent for verification.