Florida low cost alcohol and drug treatment center         

Please fill out this form and we will verify your insurance coverage for treatment.
person to contact
contact person phone number
contact person's e-mail address
patient's full name*
patient's phone number
patient's full street address
address
city
state
zip code

patient's date of birth*
patients social security number
(123-45-6789)
name of the insurance company*
name of the primary insurance policy holder
( if different from the patient i.e. spouse or parent )
patient’s policy or subscriber ID*
insurance policyholders SSN
(if known)
insurance policyholders
date of birth (if known)
group number
customer service contact phone number
substance(s) being used
alcohol pills
cocaine meth
crack marijuana
heroin not sure
Other (explain)
comments
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The Cottages of the Palm Beaches
631 US Hwy 1
Suite 304
North Palm Beach, FL 33408
Freephone:  1 866 559 2228
FAX: 1 561 966 8541




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