Insurance Verification Form Patient Name:Email: DOB:SEXMaleFemalePatient Address:Patient Phone:Insured Name:Ins. DOB:Insured Relationship:Employer:Employed:YesNoStudent:YesNoInsurance Company:Insurance Phone Number:ID#:Group#:Type of Plan:Ref:CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Testimonials Staff was very compassionate and helped me understand how serious my drinking had become Tara C.Freeport , TX We were a very confused family and were scared for our teenage daughter’s future. ADAPT helped to put us all on the road to recovery Julie P.Texas City, TX Michael and the entire staff treated me like I was a human being and not a screw up like everybody else had treated me. Andrew C.Liberty, TX I hated treatment in the beginning because I felt I didn’t belong there. Over time I really appreciated the opportunity to change. Dennis K.Manvel, TX The assistance with Suboxone really gave me the chance to focus on my recovery and not obsess about getting sick. Great service! Natalie D.Houston, TX Thank you for helping me even though I had no idea I needed it. Lana T.Bay City, TX Ms. Ruiz was extremely helpful and understanding Wade J.Angleton, TX
