Eligibility FormFirst NameLast Name Does the client have health insurance they wish to utilize for treatment? Does the client have health insurance they wish to utilize for treatment?(Required) Yes No Is paying cash an option for you? Is paying cash an option for you?(Required) Yes No Does the client have private insurance? (e,g, PPO)ย Our facility only accepts private insurance at this time. We do not accept insurance provided by the state (e.g. Washington apple health, OHP, Amerigroup, Molina, etc)Does the client have private insurance? (e,g, PPO)ย (Required) Yes No We only accept insurance through private payers. Is paying in cash an option for you? Unfortunately, Discover Recovery is a private in-patient treatment program.We only accept insurance through private payers. Is paying in cash an option for you?(Required) Yes No Please provide insurance details.Type of Insurance(Required)Select the type of insurancePPOPOSHMOTri-CareOtherHealth Insurer Name(Required)More Info(Required)Client First Name(Required)Client Last Name(Required)Client Date of Birth(Required) MM slash DD slash YYYY Member ID Number(Required)FRONT OF CARDMax. file size: 50 MB. BACK OF CARDMax. file size: 50 MB. Unfortunately, based on the provided information, we are not able to work with the client at this time. However, we have attached links and resources to help you or your loved one find help. WashingtonFindTreatment.govRainier SpringsLifeline ConnectionsOregonPower House DetoxCentral City ConcernCedar Hills Hospital We will contact you. Please provide the best way for us to get in touch.Contact Person Name (client, parent, friend, etc.)Phone(Required)Email How did you hear about us?(Required)Select OneGoogleFacebookInstagramLinkedInFriend/ FamilyAlumniYoutubeOtherThis field is hidden when viewing the formReferrer URLThis field is hidden when viewing the formReferrer URL LastThis field is hidden when viewing the formLanding Page URLThis field is hidden when viewing the formLanding Page URL LastThis field is hidden when viewing the formConverting Page URL
