Name: PACE Recovery Center
Telephone: 800-526-1851
Price range: -

Insurance Verification

Insurance Verification Form

Submit your health insurance information for verification. All information is held confidential.
Fill in all required fields (*) of the form below and we will notify you immediately when we have verification.
If you have any questions regarding the completion of this online form or about using insurance to pay for alcohol and drug rehab, please call Toll Free: 800-526-1851

You may also print and fax the form.

Patient Full Name*
Date of Birth*
Sex*
Patient Address 1*
Patient Address 2
City*
State*
Postal Code*
Patient Phone Number*
Policy Holder Number*
Policy Holder Date of Birth (DOB)*
Policy Holder Relationship*
Employer*
Employed
Student
Insurance Company*
Insurance Phone Number*
Insurance Member ID*
Insurance Group ID*
Type of Plan*
Your Email*
Additional comments
How did you hear about PACE
Name of person submitting the form*
Contact number for person submitting the form*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Insurance Verification

Insurance Verification Form

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OR CALL 800-526-1851