To get started, please have your Insurance Card ready.

Patient Information

(The person in need of addiction treatment)
Please enter patients name.
Please enter Birth Date.


Insurance Policy Holder Information
(The main person on the insurance policy)
Please enter insurance provider.
Please enter your birth date.

Please enter phone number.

Insurance Information
Please enter insurance provider.
Please enter insurance phone number.
Please enter insurance policy number.

Please enter a group ID #.
Please pland type.