OTT Insurance Verification Form

Verify Your Insurance Coverage

St. Gregory Recovery Center accepts most private insurance policies. Medicare and Medicaid are not accepted. Please provide the information below or call a St. Gregory Recovery Center admissions team member at (888) 778-5833 to help us verify insurance coverage. Your employer will not be contacted.

"*" indicates required fields

Patient Name:*

First Last

Patient Phone Number:*

Point of Contact (who should we call back if NOT Patient Name above) :

Point of Contact Phone Number:

Patient Date Of Birth:*

Email Address:*

Primary Insured Address:*

Street Address Address Line 2 City State ZIP Code

Primary Insured Name:*

Primary Insured Phone Number:*

Primary Insured Date Of Birth:*

Insurance Company Name:*

Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*

ID #:*

Group #:*

Will the patient be getting FMLA Leave while in treatment?*

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

How did you hear about us?*

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Verify Your Insurance Coverage

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