Insurance Coverage Form

If you have an insurance plan that has out of network insurance addiction coverage, we should be able to help you.
Please read about our insurance policy and call us with your information or fill out the form below to find out your coverage.

NOTE: Fields marked with (required) are needed to verify coverage and submit the form.

Your information (not necessarily the prospective patient)

Name (required)

Email (required)

Address

City

State

Zip Code

Phone #

Relation

Services Needed (required)
 Mental Health  Substance Abuse

Prospective Patient Information

Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone (required)

Date of Birth (required)

Social Security # (required)

Comments

Insurance Company Information

Insurance Company (required)

Insurance Phone # (required)

Insurance Policy # (required)

Insurance Group # (required)

Plan

Effective Date

Insurance Party Information

Insured Name(required)

Relation to Patient (required)

Social Security # (required)

Date of Birth (required)

Employer (required)

Still Employed

Term Date

By clicking the submit button, I am providing this information for use only by San Cristobal Treatment Center. Any information given will be kept private and confidential.