Pre-Qualification Form for drug treatment, and alcohol treatment
.
Pre-Qualification Form
Contact Person's Name:
Contact Person's Email Address:
Contact Person's Phone Number:
Patient's Full Name:
Patient's Phone Number:
Patient's Address:
Patient's City:
Patient's State:
Zip Code:
Patient's Date of Birth:
Name of Patient's Insurance Company:
Name of Policy Holder (if other than patient):
Patient's Policy or Subscriber ID#:
Policy Holder's Date of Birth:
Group Number:
Insurance contact number:
Substance(s) Used:
Alcohol
Cocaine
Crack
Heroin
Pills
Meth
Marijuana
Not Sure
Other
If Other, Explain here:
Comments:
How did you hear about us:
Please note:
All contact will be confidential.
Name:
Email Address:
Phone No:
Comment or Message:
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