ValueOptions Insurance Verification

Is ValueOptions your Insurance Provider? *

Who is your Insurance Provider?

Policy Holder Name *

First

Last

Client Name (if different)

First

Last

Phone Number *

Email

Upload photos of your Insurance Card? *

Date of Birth *

Plan State *

Insurance Policy ID *

Insurance Group ID *

Insurance Provider 1-800 Number (on back of card) *

Photo of Insurance Card (Front) *

Click or drag a file to this area to upload.

Photo of Insurance Card (Back) *

Click or drag a file to this area to upload.

Policy Holder Date of Birth *

Month/Day/Year

Client Date of Birth (if different)

Month/Day/Year

Will ValueOptions Cover Treatment for Mental Health and Substance Use Disorders?