Insurance Verification Form

Please fill out the form below, and we will be in touch with you shortly. Thank you.

Patient Name:*
First Last
Patient Phone:*
Point of Contact (who should we call back if NOT Patient Name above) :
Patient Date Of Birth:*
MM slash DD slash YYYY
Email Address:*
Primary Insured Address:*
Street Address Address Line 2 City State ZIP Code
Primary Insured Name:*
Primary Insured Phone Number:*
Primary Insured Date Of Birth:*
MM slash DD slash YYYY
Insurance Company Name:*
Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*
ID #:*
Group #:*
Will the patient be getting FMLA Leave while in treatment?*
FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

Newport Integrated Behavioral Healthcare, Inc

1810 Moseri Road
Decatur GA 30032