Insurance Verification

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New Life Recovery Centers

For immediate contact and Confidential Consultations – please call 408-297-1182

Complete the form and ‘Send’ – we will respond within 24 hours.

Please Note: We cannot accept Medicaid, Medi-Cal, or Medicare.

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Primary Contact(Required)

Who should we contact with insurance verification results?

Primary Contact Phone(Required)

Primary Contact Email(Required)

Preferred Method of Contact(Required)

Phone

Email

Text

Patient Name(Required)

First Last Suffix

Policy Holder Name

First Last Suffix

Policy Holder Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Relationship to Policy Holder(Required)

Date of Birth(Required)

Insurance Company(Required)

Insurance Company Phone(Required)

Insurance ID

Group Number

Which Type of Treatment Needed(Required)

Detox

Inpatient

Outpatient

Partial Hospitalization

Not Sure