Insurance Verification Form

Payment Options and Insurance Accepted

The available methods of payment at Malibu Recovery Center are:

  • Cash
  • Debit Card
  • Visa
  • Master Card
  • American Express

Insurance Accepted

Below is a list of the types of insurance we can accept for drug and alcohol addiction treatment programs:

  • Aetna PPO
  • Cigna PPO
  • United Behavioral Health (UBH) PPO
  • Some other PPO’s

Insurance Not Accepted
We cannot accept insurance from the following and you should contact your insurance company for in-network treatment referrals:

  • Medicare
  • Medicaid
  • Disability
  • HMO

*Please note: we do accept some other PPO’s and private insurance. If you do not see your insurance listed on this page, please call us for further assistance or please fill out the form below.

Patient Information

Patient Name:

Patient Phone:

Time to Contact:

Patient Email:

Patient Address:

Patient Date of Birth:

Insurance Information

Insurance Company Name :

Insurance Plan (PPO / HMO) :

Primary Card Holder:

Insurance ID #:

Group Number:

Address:

Phone (on card):

32,10,0,70,1
600,600,60,1,3000,5000,25,800
90,150,1,70,12,30,50,1,70,12,1,50,1,1,1,5000
Body
Mind
Spirit
Relationships
Alcohol