Benefits Check

Insurance Benefits Verification

By checking the box and clicking the submit button below, I am electronically submitting my signature authorizing Lifeline Connections to contact the above named insurance providers for the purpose of verifying coverage of behavioral health services including substance use disorder treatment. This release will automatically expire 30 days from today or upon my written request to revoke my consent. I understand Lifeline Connections cannot condition my potential treatment on whether I sign this consent form but the insurance benefit cannot be verified without it.
Please check the box below: