"Because We Care"
  1-877-RECOVERY
1-877-732-6837

Patient Information

Patient First Name

Patient Last Name

Patient Email

Patient Telephone

Patient DOB

Patient Social Security #

Patient Address 1

Patient Address 2

Patient City

Patient State

Patient Zip Code

Policy Holder Information

I Am The Poliy Holder

Policy Holder First Name

Policy Holder Last Name

Policy Holder Relationship

Policy Holder Email

Policy Holder Telephone

Policy Holder DOB

Policy Holder Social Security #

Policy Holder Address 1

Policy Holder Address 2

Policy Holder City

Policy Holder State

Policy Holder Zip Code

Policy Information

Insurance Company

Insurance Company Telephone (Back of Card)

Policy/Member Number

Group ID

Plan Type

Additional Comments

In accordance with HIPPA and your rights to how your private health information is handled, by submitting the above information, you are authorizing Royal Life Centers to contact you via the method you supplied. During normal business hours, we can usually verify your benefits in about an hour. However during hours aside from normal business hours, we will be able to verify your benefits first thing the following morning and return your request for help. The information you provided above will be used by our Admissions Department to assist you with all of your options while seeking treatment. We are fully committed to your privacy and confidentiality. Your information will not be used for any other purpose other than to help you find treatment and your information will not be shared with any third parties.

Patient Information

Patient First Name

Patient Last Name

Patient Email

Patient Telephone

Patient DOB

Patient Social Security #

Patient Address 1

Patient Address 2

Patient City

Patient State

Patient Zip Code

Policy Holder Information

I Am The Poliy Holder

Policy Holder First Name

Policy Holder Last Name

Policy Holder Relationship

Policy Holder Email

Policy Holder Telephone

Policy Holder DOB

Policy Holder Social Security #

Policy Holder Address 1

Policy Holder Address 2

Policy Holder City

Policy Holder State

Policy Holder Zip Code

Policy Information

Insurance Company

Insurance Company Telephone (Back of Card)

Policy/Member Number

Group ID

Plan Type

Additional Comments

In accordance with HIPPA and your rights to how your private health information is handled, by submitting the above information, you are authorizing Royal Life Centers to contact you via the method you supplied. During normal business hours, we can usually verify your benefits in about an hour. However during hours aside from normal business hours, we will be able to verify your benefits first thing the following morning and return your request for help. The information you provided above will be used by our Admissions Department to assist you with all of your options while seeking treatment. We are fully committed to your privacy and confidentiality. Your information will not be used for any other purpose other than to help you find treatment and your information will not be shared with any third parties.

Thank you!

Your insurance information has been sent for verification.

Thank you!

Your insurance information has been sent for verification.

Privacy Policy | © 2015 Royal Life Centers. All Rights Reserved.