| person to contact |
|
| contact person phone number |
|
| contact person's e-mail address* |
|
| patient's full name* |
|
| patient's phone number |
|
| patient's full street address |
|
| address |
|
| city |
|
| state |
|
| zip code |
|
|
|
| patient's date of birth* |
|
patients social security number
(123-45-6789)
|
|
| 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 SSN
(if known) |
|
insurance policyholders
date of birth (if known) |
|
| group number |
|
| customer service contact phone number |
|
| Need Help With addiction to: |
|
| Other (explain) |
|
| comments |
|
