Substance Abuse Treatment & Help - The Watershed Treatment Programs

Thursday, August 8, 2002

1000 NW 15th Street
Boca Raton, Florida 33486
Admissions: 1-800-711-6402
Clinical Services: 1-800-866-6370
info@thewatershed.com

INSURANCE COVERAGE FORM

Please complete the following form to see if you are qualified for insurance coverage. Please note, the "insured party" is not necessarily the "prospective patient". Fields marked with a "*" are required to check for coverage.

YOUR INFORMATION (not necessarily the prospective patient)

Name:
Email:
Address:
City:	State:Zip:
Telephone-Home:	Business:
Relation:

PROSPECTIVE PATIENT

*Name:
*Address:
*City:	State:Zip:
*Telephone-Home:	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 #:
*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 given be kept private and condidential.

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To protect the privacy of our clients, photographs seen on this web site do not represent actual patients.