VOB Form - Growth Extended

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SPECIALIST
about our
TREATMENT
SERVICES

1-888-476-9997

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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*
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*
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

1-888-476-9997

Contact Us

Verification of Benefits Form

or Call 888-476-9997

Proud Member of
Growth Centers of America Family

Talk to a SPECIALIST about our TREATMENT SERVICES

1-888-476-9997

Contact Us

Verification of Benefits Form

or Call 888-476-9997

Proud Member of Growth Centers of America Family

Talk to a
SPECIALIST
about our
TREATMENT
SERVICES

Proud Member of
Growth Centers of America Family