Insurance Verification

[vc_row el_class=”formread”][vc_column][vc_column_text]Baltimore Detox Center provides the highest level of care for those who are ready to overcome addiction. All you need to do is reach out to our team and verify your insurance. If you or someone you love is in need of the help of our team to end an addiction to drugs or alcohol, reach out to us today by calling [Direct] or completing our secure online form. We can help with the insurance verification process so that recovery can begin as soon as possible.[/vc_column_text]

Your Contact Information
Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
MM slash DD slash YYYY
Your Date Of Birth*
MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
- Yes
- No
Policy Holders Name*
First Last
Policy Holders Date Of Birth*
MM slash DD slash YYYY
Policy Holders Address**
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*
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Insurance Verification

Your Contact Information

Loved Ones Information

Your Information

Insurance Information