Insurance Verification

First name(Required)

Last name(Required)

Phone number(Required)

Email(Required)

Insurance Provider(Required)

Policy Membership ID(Required)

Date of Birth

This field is hidden when viewing the form

Age

Include Images of your Insurance card

Upload Front of Card(Required)

Max. file size: 512 MB.

Upload Back of Card

Max. file size: 512 MB.

Verify Approval for www.lawellnesshome.com

License Number: 191148AP

Effective Date: 11/01/24

Expiration Date: 10/31/26

ID #687210

Effective Date: 11/21/22

Expiration Date: 11/21/25

Cocaine Addiction Treatment

Marijuana Addiction Treatment

Adderall Addiction Treatment

Prescription Drug Rehab

Opioid Addiction Treatment

Opiate Addiction Treatment

facility number

Verify Approval for www.lawellnesshome.com

License Number: 191148AP

Effective Date: 11/01/24

Expiration Date: 10/31/26

ID #687210

Effective Date: 11/21/22

Expiration Date: 11/21/25

©2024 LA Wellness Home

Powered by Alecan Marketing Solutions