First, are you seeking services for yourself or someone else?
*
Myself
Someone else (e.g., family member or patient)
First Name
*
(If you are inquiring for someone else, please still enter your name here. You'll enter the patient's name towards the bottom of this form.)
Last Name
*
(If you are inquiring for someone else, please still enter your name here. You'll enter the patient's name towards the bottom of this form.)
Your Email
*
(Please enter your email address here, so our Admissions Coordinator can contact you about next steps.)
Your Phone
*
(Please enter your phone number here, so our Admissions Coordinator can contact you about next steps.)
What is your relationship to the patient?
*
Parent
Grandparent
Spouse
Sibling
Other Relative
Referring Healthcare Provider
Name of Facility or Practice (if you're a referring provider)
*
(The organization you are affiliated with)
Your Role (if you're from a referring provider)
*
(Your role at that organization)
Is the patient an adult or minor?
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Adult
Minor
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Patient First Name
*
(The person who may be receiving services at Core Recovery)
Patient Last Name
*
(The person who may be receiving services at Core Recovery.)
Parent/Guardian Email
*
Parent//Guardian Phone
*
Patient Phone
(The person who may be receiving services at Core Recovery)
Patient Email
How would you like to submit insurance information?
Upload photo of patient’s insurance card (Recommended)
Provide insurance information manually
I don’t have the patient’s insurance information available right now
Front Card
*
Back Card
*
Insurance Provider
Member ID
(Please include any prefixes, etc.)
Group Number
Is the patient the primary policyholder on the insurance policy?
Yes
No
Name of Primary Policyholder
Note: You may be the Primary Policyholder, or the Primary Policyholder may be a parent, spouse, etc.
Date of Birth of Primary Policyholder
Note: Enter the date of birth of the Primary Policyholder of the insurance policy. If you are the Primary, enter your birthdate.
Patient Date of Birth
Please type the date in this format: MM-DD-YYYY
Message
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.
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