Please fill-out this brief information form in case we need to contact you about your insurance information below. Rest assured that all information shared with us is confidential.
Are you the Primary Policy Holder for this insurance policy?
Primary Holder First Name
Primary Holder Last Name
Primary DOB Month*
Primary DOB Day*
Primary DOB Year*
Insurance Card Provider*
Customer Service Phone*
Briefly describe what substances you're struggling with and if you've ever been in treatment before. You can also use this area to add any additional information/questions that you may have for our team.
After pressing the submit button below, please wait up to one minute for your insurance data to be securely transmitted.