Insurance Verification - AACS Counseling

Insurance Verification Form

Please fill out the details below and upload a copy of your insurance card.

Full Name

Email

Date of Birth

Insurance Company

Member ID

Group Number

Subscriber Name (if not you)

Subscriber Date of Birth (if not you)

Upload Insurance Card (Front & Back)

Accepted formats: JPG, PNG, PDF (Max size: 2MB)

800-683-7745

aacscounseling.com

info@aacscounseling.com

Signup Form for Evaluation

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By providing your phone number and submitting this form you are consenting to be contacted by SMS text message. Message and data rates may apply. Reply STOP to opt out of further messaging; for more information, reply HELP. Additionally, you confirm that you have read and agree to our Privacy Policy and Terms of Service.

Please prove you are human by selecting the cup.

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Request a Call Back

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Message(Required)

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Request a Call Back

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By providing your phone number and submitting this form you are consenting to be contacted by SMS text message. Message and data rates may apply. Reply STOP to opt out of further messaging; for more information, reply HELP. Additionally, you confirm that you have read and agree to our Privacy Policy and Terms of Service.

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PAYPAL CREDIT

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By providing your phone number and submitting this form you are consenting to be contacted by SMS text message. Message and data rates may apply. Reply STOP to opt out of further messaging; for more information, reply HELP. Additionally, you confirm that you have read and agree to our Privacy Policy and Terms of Service.

Please prove you are human by selecting the cup.