Patient Information Form

Name *

First

Last

Date of Birth *

MM/DD/YYYY

Marital Status *

Comment or Message

Please explain your situation. If you would prefer to explain this to a representative on the phone, please leave this field blank.

Patient Street Address *

City *

State *

ZIP *

Insurance Company Name *

If you would like Serenity Hills Life Center to verify your insurance plan benefits, please provide your medical / mental health insurance information. All information is required. On occasion, more information is required to verify insurance benefits and eligibility. All information below is required for Serenity Hills Life Center to verify insurance plan benefits.

Insurance Company Phone Number *

Subscriber Name *

First

Last

Subscriber Date of Birth *

MM/DD/YYYY

Relationship to Subscriber *

Subscriber's Employer *