Name: Clear Life Recovery
Address: 2822 Monterey Ave, Costa Mesa, CA, 92626, US
Telephone: (866) 210-4371

You’re ready to get help for your addiction. What’s next? Recent legislation provides coverage for addiction like any other medical illness. Clear Life Recovery works with various insurance providers to help you get health care coverage for addiction treatment.

Fill out this insurance verification form so we can help you through the necessary paperwork. You are taking the first step to recovery!

Your Contact Information
Your Name*
First Last
Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
MM slash DD slash YYYY
Your Date Of Birth*
MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify insurance benefits?*
- Yes
- No
Policy Holders Name*
First Last
Policy Holders Date Of Birth*
MM slash DD slash YYYY
Policy Holders 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*
Subscriber relationship to client*
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Your Contact Information

Loved Ones Information

Your Information

Insurance Information