VOB Form – Adolescent Growth

Talk to a
SPECIALIST
about our
TREATMENT
SERVICES

1-888-948-9998

Verification of Benefits Form

Find out if your insurance will cover the entire cost of treatment for your teen or adolescent. Fill out the form below and one of our representatives will contact you shortly.

Name of client*
First Middle Last
Your Contact Number*
Client/Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Client/Patient Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Care Requested*
- Residential
- Partial Hospitalization
- Intensive Outpatient
Name of Insured*
First Middle Last
Relationship to client/patient
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance Provider(Name of your insurance company)*
Member ID Number
Group Number
Number on the back of the card (for providers)
Through/Employer

Talk to a SPECIALIST about our TREATMENT SERVICES

1-888-948-9998

Verification of Benefits Form

Talk to a
SPECIALIST
about our
TREATMENT
SERVICES