Insurance Provider Form

Please fill out the form below to provide us information pertaining to your insurance provider:

Insurance Provider Form

Insurance Types

Patient Information

Patient Name(Required)

Patient DOB(Required)

Contact Number for Assessment(Required)

Insurance Provider(Required)

Select type of funding(Required)

Medicaid ID(Required)

Referral Source

Name(Required)

Number(Required)

Company(Required)

Please upload your patients clinicals and any other pertinent information

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 100 MB, Max. files: 10.

Please upload your patients clinicals, insurance details, and any other pertinent information

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 100 MB, Max. files: 10.

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Phone

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

Step 1

Complete our easy form

Step 2

Set up assessment

Step 3

Coordinate Transportation

(844) 478-6563

CONTACT US

Find out how we can help

Our compassionate counselors are standing by to answer any questions you may have. After helping thousands of people over the last 50 years, we have the resources to help you and your family and all your individual needs.

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We Accept Most Insurances

Transportation Provided PE Medicaid Provider Weekend Admissions

Get Help Now

Looking for addiction help for yourself or a loved one? Our professionally trained admissions coordinators are always available to assist you with any questions you might have.

Make a Referral

For professional client referrals, please call our helpline and ask to be directed to the outreach team. You can also submit a contact form below to schedule a call with us.

Schedule a Tour

If you are an addiction professional interested in our services, we would love to arrange a tour of our treatment facility with you.

Dr. Michael DeShields, MD, ASAM, DABAM( Medical Reviewer )

Dr. Michael DeShields, MD, ASAM, DABAM, is a distinguished Medical Director with nearly 40 years of expertise in addiction medicine. A diplomate of the American Board of Addiction Medicine and the American Society of Addiction Medicine since 1996, he is renowned for his leadership and commitment to evidence-based, patient-centered care. Dr. DeShields earned his medical degree from Temple University School of Medicine and completed his training at Cooper University Medical Center, where he cultivated his passion for addiction treatment. His dedication and innovation continue to shape the field, guiding clinical teams and supporting patients on their recovery journey.

Insurance Provider Form