Insurance Form

Please provide some basic information,

*Required fields

Name (First, Middle, Last):*

Address:*

City:*

State:*

Zip:*

Phone:*

Evening Phone:*

Fax:

Email:*

Prospective Patient (All fields Required)

Name (First, Middle, Last):*
 Address:*
  
     
City:*
 State:*
 Zip:*
  
     
Phone:*
Evening Phone:*
     
Date of Birth:*
Social Security Number:*
     

Comments:* Addiction details,  Emotional Concerns, Health conditins, Objectives

 

Insurance Company (All fields Required)

Insurance Company Name:*
 Insurance Company Phone Number:*
  
     
Policy Number:*
 Insurance Group Number:*

  
     
Plan:*
Effective Date:*
  

Insured Party (All fields Required)

Insured Name:*
 Relation to Patient:*
  
     
Social Security Number:*
 Date of Birth:*
  
     
Employer:*
Term Date:*
  
     
Date of Birth:*
Social Security Number:*
  
     

Self Employed:* Occupation

    


Upon receipt and review we will respond to you promptly. If your situation is life threatening, please call 911.

Copyright © 2000, AAERetreat ~ Crosby Centers. All rights reserved.
AA&E Retreat/ Crosby Centers are recognized around the world as leaders in Addiction and Mental Health Treatment.
The success of our programs have given patients their best opportunity to reclaim their life and achieve sustained recovery.
We are a private-pay facility. Fully Licensed by the State of California.
THE COMPREHENSIVE WHOLE PERSON 'holistic' TREATMENT