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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We Accept Most Insurances

Transportation Provided PE Medicaid Provider Weekend Admissions

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Discovery Institute( Medical Reviewer )

Provide the highest quality clinical care through evidence-based treatment practices and innovative supportive strategies to improve and heal the lives of individuals suffering from substance use disorder. It’s our goal to lessen the adverse impact on families and society as a whole through providing a range of cutting-edge treatment modalities and individualized treatment plans for all of our clients and their families.

Insurance Provider Form