Name

Email Address*

Phone Number*

PATIENT INFORMATION

Patient Name*

Street Address

City

State

Zip

Patient D.O.B* (m/d/yy)

Patient SS NO

Substance(s) Used

Amount Used

Method of Use (Snort, Shoot, etc

Frequency (Daily, Weekly, Monthly)

Length of use

Current Medications

Medical or Health Issues

Detox Needed?

Previous Treatment (list all)

PLAN INFORMATION

Insurance Provider

Plan Type

ID Number

Group Number

Provider Phone No

Employer

SUBSCRIBER INFORMATION (If different from Identified Patient)

Subscriber Name

Subscriber D.O.B (mm/dd/yyyy)

Subscriber SS NO

Street Address

City

State

Zip

INTERNAL USE ONLY

Benefits

Deductible

Co-Pay

Days Pre Auth

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