Verify Your Insurance

Secure Online Form

Cottonwood works with all major insurance programs and is in-network with Aetna, Beacon, Humana, and First Health.

Submit your health insurance information for verification. All information is held confidential.

Fill in all required fields (*) of the form below and we will notify you immediately when we have verification.

If you have any questions regarding the completion of this online form or about using insurance to pay for alcohol and drug rehab or mental health treatment, please call Toll Free: (888) 727-0441.

"*" indicates required fields

Patient Name:*

First Last

Patient Phone Number:*

Point of Contact (who should we call back if NOT Patient Name above) :

Point of Contact Phone Number:

Patient Date Of Birth:*

Email Address:*

Primary Insured Address:*

Street Address Address Line 2 City State ZIP Code

Primary Insured Name:*

Primary Insured Phone Number:*

Primary Insured Date Of Birth:*

Insurance Company Name:*

Insurance Company Phone Number for Providers (Mental Health or Substance Abuse):*

ID #:*

Group #:*

Will the patient be getting FMLA Leave while in treatment?*

FMLA refers to the Family and Medical Leave Act, which is a federal law that guarantees certain employees up to 12 workweeks of unpaid leave each year with no threat of job loss. FMLA also requires that employers covered by the law maintain the health benefits for eligible workers just as if they were working.

How did you hear about us?*

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