Many people that visit our website are ready to begin a new life. This can be your first step toward getting your life back.

Please fill out the insurance information form below to allow the Brookhaven team to quickly verify your coverage. From there, we will coordinate your arrival and begin your walk toward Recovery.

Note: Fields with an asterisk (*) are required.

Name*:
Address*:
Phone Number*:
Email*:

Prospective Patient

Name*:
Address*:
City*:  State*: ZIP*:
Telephone (Home)*:
Telephone (Bus.)*:
Date of Birth*:
Please let us know of any special circumstances and how we should contact you and/or the prospective patient.
Comments:

Insurance Company

Company Name*:
Company Phone*:
Policy #*:
Insurance Group #*:
Plan*:
Effective Date*:

Insured Party

Insured Name*:
Relation to Patient*:
Date of Birth*:
Employer*:
Self Employed*:  Length:
Term Date*: