Verify Your Insurance Royal Life Centers | Quality Drug and Alcohol Addiction Treatment

Patient Information

First Name

Last Name

Phone Number

D.O.B.

Social Security Number

Patient Address

Line 1

Line 2

City

State

ZIP

Policy Holder Information

I am the Policy Holder

First Name

Last Name

Phone Number

D.O.B.

Social Security Number

Policy Holder Address

Line 1

Line 2

City

State

ZIP

Policy Information

Insurance Company

Insurance Company Telephone (Found on back of Card)

Policy/Member Number

Group ID

Plan Type

Additional Comments

In accordance with HIPPA and your rights to how your private health information is handled, by submitting the above information, you are authorizing Royal Life Centers to contact you via the method you supplied. During normal business hours, we can usually verify your benefits in about an hour. However during hours aside from normal business hours, we will be able to verify your benefits first thing the following morning and return your request for help. The information you provided above will be used by our Admissions Department to assist you with all of your options while seeking treatment. We are fully committed to your privacy and confidentiality. Your information will not be used for any other purpose other than to help you find treatment and your information will not be shared with any third parties.