Preserve your skin.

INSURANCE

Call 954-453-7701 for Help.

Investigational Health Study for Adults: There are no direct medical benefits for participating in this study.

You will receive one phone call after the form below is filled out. The phone call will last roughly five minutes. You will be asked to go over the answers you provided on the questionnaire. Anyone who chooses not to go to rehab, will be given the opportunity to join our one year long study for people not going to rehab. Anyone who willingly goes to rehab, will be given the opportunity to join our one year long study for people in and out of rehab.

No insurance?

No problem. In a country where getting quality help for your health is still a slippery slope, we make sure you don't have to sacrifice a healthy, happy future for the sake of financial struggles. Because of our diverse and trusted database of facilities, our caring counselors and representatives work hard to find treatment options for everyone. Even if you don't have insurance, we will find an affordable or low-cost program that fits within your budget constraints.

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.



Insurance Verification
 


 
Did you purchase your policy through the Health Insurance Exchange?

 
Policy #*
Insurance Phone*
 
 
 
 
 
Insured Name*


 
 

Insured SSN
 
 
Client Name



 
 
Client Age
Client SSN
Client DOB
     






Address On File With Insurance Company
 
Address

Street Address
 

Address Line 2
 

City
 

State
 

ZIP Code
 
Client's Phone*
 
Recent Substance Use by Substance (How much/How Often)
 
Treatment History





Contact Person Once Verification is Complete
 
Name


 
 
Primary Phone
Secondary Phone
 
 
Email
Best Time to Contact
:
 
 

*Validation: