Patient Information
(*) Obligatory Field
(The person in need of addiction treatment)
Your personal information is safe & SSL encrypted
Please enter a valid name.
The primary insured person's date of birth - DD/MM/YYYY
Date of birth must be in this format: MM/DD/YYYY.
Invalid phone number
Insurance Policy Holder Information
(The main person on the insurance policy)
Enter the name of the primary person on the insurance policy.
The primary insured person's date of birth - DD/MM/YYYY
Date of birth must be in this format: MM/DD/YYYY.
Invalid email address entered.
Phone must be 10 digits (123) 456-7890.
Insurance Information
Enter your insurance provider.
Enter your insurance company's phone number.
May be listed as Policy or Member number
Enter your insurance ID number.
Enter your insurance policy group number.
Type of Plan (*)
PPO
POS
EPO
HMO
Usually listed in a small box in the corner of your card. Examples included PPO, HMO, EPO, POS
Select your Type of Plan.
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