* = required fields
First Name
*
John
Last Name
*
Smith
Phone
*
555-555-5555
Email
*
jsmith@mail.com
Insurance Provider
*
1
Aetna
Policy Membership ID
*
XY29MK91
Group Number
*
12345
Date of Birth
*
01/03/1991
Do you have a history of drug or alcohol use? *
Yes
No
Are you located in The United States of America? *
Yes
No
Do you have any intention to harm yourself or others? *
Yes
No
Are you experiencing a psychotic episode? *
Yes
No
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1Insurance Disclaimer: American Addiction Centers will attempt to verify your health insurance benefits and/or necessary authorizations on your behalf. Please note, this is only a quote of benefits and/or authorization. We cannot guarantee payment or verification eligibility as conveyed by your health insurance provider will be accurate and complete. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” American Addiction Centers will make every effort to have all services preauthorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under your plan, your insurer will deny payment for that service and it will become your responsibility.