Upfront Recovery LLC

Verify Insurance

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VERIFY INSURANCE

Insurance Information
Insurance Name*
Insurance Phone #*
Policy Holder*Full Name
Policy Holders*Phone Number
Member ID #*
Group #*
Patient's Information
Patient's Full Name*
Patient's DOB*Date of birth
Policy holder DOB*Date of birth
Patient's Address*on File w/ Insurance Company
Patient's Phone #*
Presenting Substance*
Date of last use*
Amount of Time You Have Consumed Substance*
Have You Been To Treatment In The Last Year*
Amount of use*per day