Drug Addiction Treatment Center the watershed addiction treatment programs The Watershed Addiction Treatment programs offering drug addiction treatment as well as alcohol addiction treatment. America's premier drug addiction treatment center 24 hour addiction treatment helpline at the watershed addiction treatment programs for drug addiction

Insurance Coverage Form

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YOUR INFORMATION

Not necessarily the prospective patient

Name

*Email

Address

City, State, Zip

Home Phone

Business

Relation

PROSPECTIVE PATIENT

*Name

*Address

*City

City, State, Zip

*Home Phone

Business

*Date of Birth

*Social Security

Comments

Please let us know of any special circumstances and how we should contact you and/or the prospective patient.

INSURANCE COMPANY

*Insurance Company

*Insurance Phone

*Policy No

*Insurance Group

Plan

Effective Date

INSURED PARTY

*Insured Name

*Relation to Patient

*Social Security

*Date of Birth

*Employer

Still Employed

Length

Term Date:


I am providing this information for use by The Watershed only. Any information will be kept private and confidential.

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