Insurance Verification Form

We understand that insurance and funding, in general, can be overwhelming. You can find some additional information here or you can talk to our admissions team at 435-272-1280

ThreePeaks Ascent values and respects your privacy. ThreePeaks Ascent will make every effort to ensure that the information you provide to us is kept private and only shared with individuals/organizations that you approve of.

Your Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Insurance Information

Insurance Carrier(Required)

Insurance Phone Number(Required)

Insurance ID Number(Required)

Insurance Group Number(Required)

Policy Holder Name(Required)

First Last

Policy Holder's Employer(Required)

Child Information

Child's Name(Required)

First Last

Gender(Required)

Male

Female

Date Of Birth(Required)

Age(Required)

Other

Zip

Name

This field is for validation purposes and should be left unchanged.

Insurance Verification Form

Your Information

Insurance Information

Child Information

Other

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