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Am I Covered?
Many people visit our websites and in turn want to begin a new life with our easier, softer detox methods. Below you will find our insurance verification form which will help us determine whether you are covered. We also have a scholorship rate which applies for those individuals who wish to self pay. This rate is all inclusive which means unlike most institutional facilities our rate covers doctors fees, all medication, snacks, gourmet meals, hydrotherapy ect . . . YOUR INFORMATION (not necessarily the prospective patient)
Name:
Address:
Phone Number:
Email: (Required)
PROSPECTIVE PATIENT(All Fields Are Required)
Name:
Address:
City:	State: ZIP:
Telephone (Home):
Telephone (Bus.):
Date Of Birth:
Comments:
Please let us know of any special circumstances and how we should contact you and/or the prospective patient.
INSURANCE COMPANY(All Fields Are Required)
Insurance Company Name:
Insurance Company Phone:
Policy #:
Insurance Group #:
Plan:
Effective Date:
INSURED PARTY(All Fields Are Required)
Insured Name:
Relation To Patient:
Date of Birth:
Employer:
Self Employed:	No Yes  Length:
Term Date:

Prescriptions for drugs used as part of the therapeutic process are based on a face-to-face medical consultation by staff physicians.