Admissions

Your first step towards a better life

Insurance Verification

Let us help you every step of the way, from working with your insurance company to booking travel arrangements
Please complete the form below and a HARP representative will contact you shortly.

Your Name:

Patient Email:

Phone Number:

Address:

City:

State:

Zip:

How are you feeling?

Any other comments/questions?

Patient Name:

Patient D.O.B.:

Policy Holder Name:

Policy Holder D.O.B.:

Relation to Patient:

Insurance ID #:

Do you have insurance?
YesNo

Insurance Provider:

Substance abuse or mental health:
Substance AbuseMental Health

Have you been in treatment for drugs or alcohol previously?
YesNo

If so, when and where?

Type of care you are interested in?

Substance abused:

Payment Method:

Semi-private or Private room?

Will you require transportation?
YesNo

Additional Admission Information

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