Verify Your Insurance - Illinois Recovery Center

"*" indicates required fields

Patient Information

Please fill out the information below for the individual who is in need of treatment. For phone number and email address, please provide the best contact information – whether it be your own contact info or someone else’s.

Patient Name*

First Last

Date of Birth*

Gender*

Marital Status*

Relationship to Insurance Policy Holder*

Best Contact Phone Number*

Best Contact Email Address*

Please Describe the Situation

How Did You Hear About Illinois Recovery Center?

Insurance Information

Please be as thorough as possible when entering your insurance information. All information contained in this form is secured / encrypted and is protected by HIPAA.

Insurance Company*

Plan Type

Example: PPO, HMO, POS, EPO, etc.

Member ID*

Insurance Company Phone Number*

Please reference the toll-free number on the back of your insurance card.

Primary Policy Holder's Name*

Primary Policy Holder's DOB*

Primary Policy Holder's Employer

Primary Policy Holder's ZIP Code

This field is for validation purposes and should be left unchanged.