Insurance Verification Form | The Gooden Center

Please fill out the insurance verification form below and one of our experienced admissions specialists will find out exactly what your insurance will cover and get back to you, usually within a few hours.

Name*
First Last
Address*
Street Address City State ZIP Code
Your Email*
Date of Birth*
MM slash DD slash YYYY
Insurance Company*
Member Services Phone Number*
Member ID*
Group #*
Contact Person Once Verification is Complete
Either an email or primary phone will be required in order to contact you.
Name*
Primary Phone*
Secondary Phone*
Email*
The Gooden Center fully complies with HIPPA regulations and will only contact you regarding confidential health matters in ways that you explicitly authorize. Providing us with the above contact information authorizes the Gooden Center to contact you via that method. The more methods of contact that you provide, the more quickly you will get an answer. For your own privacy, choose the method of contact least likely to be checked by other parties. Once you have submitted this form you are explicitly authorizing us to use the information you provide to contact your insurance company in order to verify your eligibility for insurance benefits to cover the cost of treatment. The above information you supply will also be used by an Admissions Counselor at the Gooden Center to provide you with a number of treatment options. Under no circumstances will your confidential information be shared with third parties or used for any other purpose than stated herein.
Untitled*
- I have read and accept the Privacy Policy.

Contact Person Once Verification is Complete

Either an email or primary phone will be required in order to contact you.