Verify Insurance

Insurance Verification Form for English Mountain Recovery

We are in-network with the following insurance:

Optum magellen health insurance

Please be aware that insurance benefits and policies vary greatly. At EMR our trained admissions staff will help you obtain information on your policy. However, EMR does not have any control over the outcome of these reviews, and these reviews do not guarantee payment by your insurance company upon final billing by EMR.

We would like to make you aware, EMR cannot hold your insurance company responsible for payment. EMR contracts with you when you sign our financial agreement upon admission. This agreement obligates you to pay for services received while at EMR. If your insurance company does not cover all of your treatment costs the balance will be your responsibility.

"*" 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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