Gateway Rehabilitation Insurance Verification Forms

Gateway offers both in-network and out-of-network insurance options for individuals working to free themselves from addiction. Verify your insurance today by filling out the insurance verification form below or give us a call at 877.505.4673.

Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A loved one
How did you hear about us?
Loved One's Information
Your Information
Loved One's Name*
First Last
Loved One's Date Of Birth*
Date Format: MM slash DD slash YYYY
Your Date Of Birth*
Date Format: MM slash DD slash YYYY
Additional Information
Insurance Information
Policy Holder's Name*
First Last
Policy Holder's Date Of Birth*
Date Format: MM slash DD slash YYYY
Client's Date Of Birth*
Date Format: MM slash DD slash YYYY
Policy Holder's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
RX BIN*
Subscriber relationship to client*
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Addiction Destroys Dreams, we can help.

Addiction Destroys Dreams, we can help.

Addiction Destroys Dreams, we can help.

Addiction Destroys Dreams, we can help.

Addiction Destroys Dreams, we can help.

Addiction Destroys Dreams, we can help.

Loved One's Information

Your Information

Insurance Information

Call Gateway Now for Life-Changing Care:

877.505.4673

Call Gateway Now for Life-Changing Care:

877.505.4673

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