February 7, 2012

Will Insurance Cover Treatment?

By entering the insurance info your interventionist will be able to match the loved one with a clinically appropriate center with the lowest possible out of pocket cost. Just fill out the form below with all the information you have. We will get back to you ASAP and let you know what is covered. Questions? Call us at 866-961-5810

Your Name:
Phone:
Email:
Address 1:
Address 2:
City:
State:
Zip code:
Age:

Comments or Questions:

Drug being used:
Payment Method:
Do they need transportation?	Yes no
Your insurance Provider:
Patient Name:
Patient Date of Birth:
Policy Holders name:
Policy Holders DOB:
Relation to patient:
Insurance ID number:
Insurance phone number:
Have thry benn though drug or alcohol treatment before?	Yes no