Insurance Verification

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Fill out the confidential form with your name, number and insurance provider
Someone from our staff will contact your insurer to verify your policy could cover your treatment
We will contact you within an hour with the results and discuss the next steps

First Name

Last Name

Phone Number

Date of Birth

Insurance Provider

Member ID

By sending this email I am requesting that you contact my insurance company to verify benefits. I understand that you may need to call me if my insurance company requires more information than supplied on this form.

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Pure Recovery LIC

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