Crosby Drug and Alcohol Addiction Treatment Center

Home | Facilities | Programs / Treatments | NSI, Brain Systems | Individualized Outpatient Programs | Contact Us / Details
 

Finance And Insurance Inquiry

We offer treatment financing to help with the tremendous costs associated with drug, alcohol, and mental health treatment. Please provide some basic information and we will try to help-,

*Required fields

Name (First, Middle, Last):*

Address:*

City:*

State:*

Zip:*

Phone:*

Evening Phone:*

Married/Single, Family Members:*

Email:*

Prospective Patient (All fields Required)

Name (First, Middle, Last):*
 Address:* Own or Rent
  
     
City:*
 State:*
 Zip:*
  
     
Phone:*
Estimated Monthly Income:*
     
Date of Birth:*
Social Security Number:*
     

Comments:      A-1 * The Addiction details,                 A-2  * Do You Have Family Financial Support?

 

Insurance Company (All fields Required)

Insurance Company Name:*
 Insurance Company Phone Number:*
  
     
Policy Number:*
 Insurance Group Number:*

  
     
Plan:*
Effective Date:*
  

Insured Party (All fields Required)

Insured Name:*
 Relation to Patient:*
  
     
Social Security Number:*
 Date of Birth:*
  
     
Employer/Self-Employed-Occupation*
Term Date:*
  
     
Date of Birth:*
Social Security Number:*
  
     

Self Employed:* * Estimated Annual Income   * Family Guarantor

    


Upon receipt and review we will respond to you promptly. If your situation is life threatening, please call 911.

Copyright © 2000, AAERetreat ~ Crosby Centers. All rights reserved.
AA&E Retreat/ Crosby Centers are recognized around the world as leaders in Addiction and Mental Health Treatment.
The success of our programs have given patients their best opportunity to reclaim their life and achieve sustained recovery.
We are a private-pay facility. Fully Licensed by the State of California.
THE COMPREHENSIVE WHOLE PERSON 'holistic' TREATMENT