Patient Information (*) Obligatory Field

(The person in need of addiction treatment)

The primary insured person's date of birth - DD/MM/YYYY
Invalid phone number

Insurance Policy Holder Information

(The main person on the insurance policy)

The primary insured person's date of birth - DD/MM/YYYY

Insurance Information

May be listed as Policy or Member number
Usually listed in a small box in the corner of your card. Examples included PPO, HMO, EPO, POS