Verify Insurance

MD Home Detox accepts and/or is covered through most PPO insurance plans. If you would like us to verify your coverage, eligibility, and benefits information for behavioral and mental health treatment services please fill out the form below. Once complete, an admissions counselor will contact you with an explanation of the benefits available on your specific insurance plan. Insurance benefits can only be verified Monday through Friday during normal business hours. If you provide your insurance information after 5PM PST you will be contacted the following day.

  • EPO’s
  • HMO’s
  • LA Care
  • Medi-Cal
  • Medicare
  • Medicaid

General Insurance & Insured Information

INSTRUCTIONS: We advise that you fill out this section completely. Only the prompts with asterisks are required. Some insurance companies require all the information in this section for HIPPA verification purposes. Please submit phone numbers in the following format: (XXX)XXX-XXXX.

Insurance Company

Client Name (required)

Insurance Provider / Customer Service Phone

Client Date of Birth (required)

Member Services Phone

Type of plan (required)

Client Social Security Number


Please Include ALL Letters and Numbers for Member ID and Group Number:

Member ID (required)

Group Number


Address on File With the Insurance Company:

INSTRUCTIONS: Some insurance companies (United Healthcare) require the primary plan holders address on file with the insurance company for HIPPA verification purposes. Remember, this is the address where you receive billing and benifits information from your insurance company.

Street Address

Address Line 2

City

State

Zip Code

Country

Client's Phone


Presenting Problems & Treatment History:

INSTRUCTIONS: We advise that you fill out this section completely. Only the prompts with asterisks are required. PRESENTING PROBLEM examples would be; alcoholism, drug abuse, depression, cocaine, dual diagnosis, gambling addiction, etc. Please be as through as possible in the TREATMENT HISTORY section.

Services Needed

Presenting Problem

Prior Treatment

Treatment Date

Treatment History


Contact Person for Follow Up Regarding Coverage:

INSTRUCTIONS: We advise that you fill out this section completely. Only the prompts with asterisks are required. This is how we will contact you after we speak with your insurance company. Please submit phone numbers in the following format: (XXX)XXX-XXXX.

Name (required)

Phone (required)

Secondary Phone

Email

Best Time to Contact


Authorization & Confidentiality Notice:

IMPORTANT INFORMATION: By filling out and submitting this form, you are explicitly authorizing us to use the information provided to contact your insurance provider for the purpose of verifying eligibility, benefits, and coverage information for behavioral and mental health treatment services. Either a phone number or email is required in order to contact you to report our findings. In compliance with HIPPA regulations, we may only contact you regarding confidential health matters in ways that you explicitly authorize. When you provide your primary phone number or email, you are authorizing us to contact you via that method. For your privacy, utilize the method of contact that is least likely to infringe on your confidentiality or be reviewed by other parties. The information you provide will also be used by an Admissions Counselor to provide you with treatment options. Your information will not be shared with third parties or used for any other purpose than stated above. CONFIDENTIALITY NOTICE: The above submission form is protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed to anyone other then those outlined above without written consent unless otherwise provided for in the regulations. The Federal rules prohibit any further disclosure of this information unless a written consent is obtained from the person to whom it pertains. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.