Insurance Verification

We’ve made our insurance verification process as simple as possible so that recovery can begin right away. At New Hampshire Detox Center, we accept Medicaid as well as private insurance. Don’t let concerns about the cost of treatment keep you from reaching out for help. Fill out the simple form below and contact our team at 603.932.7692 with any questions.

Your Contact Information
Your Name*
First Last
Return Callback 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 your or a loved ones 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*
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Your Contact Information

Loved Ones Information

Your Information

Insurance Information

Recovery
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New Hampshire Detox Center

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Rebirth, Regrowth, Renewal

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