Insurance

Park Bench will determine insurance benefit eligibility or help make special arrangements for payment. Most insurances, credit cards, and flexible direct payments are all accepted.

Please Allow Us to Verify Your Medical Insurance Coverage for Treatment

Person to contact: *

Person's phone number: *

Contact person's e-mail address: *

Patient's full name: *

Patient's phone number: *

Patient's full street address:

City:

State:

Zip Code:

Patient's date of birth: *
/ /
month/day/year (eg. 04/14/1963)

Subscribers name:

Name of the insurance company: *

Name of the primary insurance policy holder:

(if different from the patient i.e. spouse or parent)

Patient's policy or subscriber ID: *

Insurance policyholders date of birth (if known):
/ /
month/day/year (eg. 04/14/1963)

Group number:

Insurance customer service phone number:

Substance(s) being used:

Alcohol
Cocaine
Crack
Heroin
Pills
Meth
Marijuana
Not sure

Other (explain) :

Comments:

How did you hear about us?