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 877.381.6538.

First Name *

Last Name *

Return Callback Phone Number *

Email Address *

Who is seeking treatment? * YourselfA loved one

How did you hear about us *

Insurance Information

Policy Holder’s First Name *

Policy Holder’s Last Name *

Policy Holder’s Date of Birth *

Client’s Date of Birth *

Policy Holder’s Address *

City *

ZIP *

State *

Insurance Company’s Name *

Insurance Company’s Phone Number *

Member ID *

Group Number *

RX BIN *

Subscriber Relationship to Client *

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Individualized, evidence based treatment, to fit your needs.

Individualized, evidence based treatment, to fit your needs.

Individualized, evidence based treatment, to fit your needs.

Individualized, evidence based treatment, to fit your needs.

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Insurance Verification Forms

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