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Am I Covered? Print E-mail
Please fill out our secure form so we can verify benefits with your insurance company. If you fill this out during normal business hours we will contact you the same day, If you fill this out after hours we will contact you the next morning. Privacy Policy: This information is private and will never be shared with any other organizations.

How Did You Hear About Us?
First Name
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Address
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City
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State
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Zip Code
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Phone Number (Should be 10 digits... like this: 305-555-2121)
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Email Address (Should look like this: brandon@gmail.com)
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Age
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Social Security Number of Patient (Should look like this: 591-33-2121)
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Birth Date of Patient (Should look like this: 5-10-75)
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Name On Insurance Card?
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Insurance Company
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Policy Number
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Insurance Group Name or Number?
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Insurance Company Phone Number (Should be 10 digits... like this: 800-555-1212
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Are You Drinking Alcohol?
Explain A Little About Your Drinking, Explain in Detail... How Much and How Often?
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Are You Taking Drugs?
Are You On Any Medications?
What Drugs or Medications Are You Currently Taking and How Much? ...Explain In Detail and include Everything!
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How's Your Health?... Please Explain Any Health Issues.
How Should We Contact You?
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You can write us an email anytime by clicking on one of the links below... Help is only a mouse click away.

Send an Email - Ask a Question Send an Email - Addict to Addict Send an Email - Length of Stay Send an Email - Am i Covered Ask A Question
Prescriptions for drugs used as part of the therapeutic process are based on a face-to-face medical consultation by staff physicians.