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Note: any and all information submitted is completely confidential
 
 
Last Name :: This information is recommended but not required - all correspondence with Treatment-Centers.net is completely confidential in full recognition and cooperation with Federal HIPPA laws.
 
Email Address :: A valid email adress of the form email@yourdomain.com is required
 
Phone Number :: Please include area code or country code if outside US
 
 
 
 
 
 
 
 


















What is/are The Primary Drug(s) of Abuse? :: Check All That Apply
 

Drug History

 
 
 
 
 
 
 
 

Medical History

 
 
 
 
If Yes, Please Select The Type of Insurance The User Has :: Private health insurance is provided by companies like Blue Cross, Aetna, Cigna, and many full time employee benefits offer private PPO health insurance plans. These plans are the most likely to pay for private treatment. HMO plans are offered by the same private health insurance companies, but tend to have less sufficient inpatient substance abuse benefits - it is best to conact the insurance company to understand these benefits, as they vary for each individual plan. Medicare and Medicaid are publicly funded insurance plans and are not generally accepted at private pay treatment centers. Medicare and Medicaid will only pay for publicly funded treatment centers. Please search the treatment directory's treatment locator to find the publicly funded treatment centers in your area if the only insurance available is Medicare or Medicaid.
 
If Necessary, How Much Out-of-Pocket Money is Available for Private Rehab? :: quality private rehab starts around $10,000 for 30 days of treatment without medical isurance. If there is no money or insurance to pay for treatment, you need to look for publicly funded rehab in the user's area by using the treatent center locator in the drop down of the Treatment Directory tab.
 
 
 
 
  
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