Please Include ALL Letters and Numbers for Member ID and Group Number:


Address on File With the Insurance Company:

INSTRUCTIONS: Some insurance companies (United Healthcare) require the primary plan holders address on file with the insurance company for HIPPA verification purposes. Remember, this is the address where you receive billing and benefits information from your insurance company.


Presenting Problems & Treatment History:

INSTRUCTIONS: We advise that you fill out this section completely. Only the prompts with asterisks are required. PRESENTING PROBLEM examples would be; alcoholism, drug abuse, depression, cocaine, dual diagnosis, gambling addiction, etc. Please be as thorough as possible in the TREATMENT HISTORY section.

Service Needed:


Prior Treatment:


Treatment Date:


Contact Person for Follow Up Regarding Coverage:

INSTRUCTIONS: We advise that you fill out this section completely. Only the prompts with asterisks are required. This is how we will contact you after we speak with your insurance company. Please submit phone numbers in the following format: (XXX)XXX-XXXX.

Authorization & Confidentiality Notice:

IMPORTANT INFORMATION: By filling out and submitting this form, you are explicitly authorizing us to use the information provided to contact your insurance provider for the purpose of verifying eligibility, benefits, and coverage information for behavioral and mental health treatment services. Either a phone number or email is required in order to contact you to report our findings. In compliance with HIPPA regulations, we may only contact you regarding confidential health matters in ways that you explicitly authorize. When you provide your primary phone number or email, you are authorizing us to contact you via that method. For your privacy, utilize the method of contact that is least likely to infringe on your confidentiality or be reviewed by other parties. The information you provide will also be used by an Admissions Counselor to provide you with treatment options. Your information will not be shared with third parties or used for any other purpose than stated above. CONFIDENTIALITY NOTICE: The above submission form is protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed to anyone other than those outlined above without written consent unless otherwise provided for in the regulations. The Federal rules prohibit any further disclosure of this information unless written consent is obtained from the person to whom it pertains. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

How MD Home Detox Works

Initial Consultation
We meet with you and your family to get more information and create a personalized detoxification plan and outline a follow-up plan of action. Options for detox include a 100% safe, at-home medical detox with 24-hour nursing care or a transition to a medical facility for more complex cases.
Coordination
We coordinate each client's individualized care which includes the medical personnel who will monitor and facilitate the detox. Our admissions counselors may refer you to a therapist or other necessary service providers, such as recovery companions for daily coaching to support client goals.
Services
We coordinate services related to each client's health and wellness needs, including concierge services related to nutrition, exercise, spiritual enhancement, creative expression, education and social skills support.
Family Education
We assess and work with the client's family, including referring to family therapy, support groups and educational workshops. We provide thorough education on the detox process in terms of what to expect for both clients and families.
Referrals
For those who need more intensive treatment, we offer guidance and referrals to residential treatment facilities or intensive outpatient programs, all from within our large professional network.
Call 1-844-243-4832