× Fill Form or Proceed to Site: Full Name: Are You PR Member: Select YES No How Do You Want To Be Contacted: Select Phone No Email Reason For Contact: Select I am looking for treatment Treatment for a loved one Looking for more information Peer Recovery Specialist Inquiry Are You 18+ Select YES No Are You Contacting For You or Loved One: Select For Myself For Loved One When are you looking to go? Select Immediately 2 Days 1 Week 2 Weeks 1 Month Other What Type Of Treatment You Are Looking For: Select Inpatient Outpatient Detox Long term Treatment LGBTQ or Gender Specific Virtual Mental Illness: Select YES No UNKNOWN Have Health Insurance: Select YES No Select Insurance Company 1199 National Benefit Fund (SEUI) AARP ABSOLUTE TOTAL CARE ADMINISTRATIVE SERVICES INC AETNA AFFINITY HEALTH PLAN AFTRA HEALTH FUND ALAMEDA ALLIANCE HEALTH PLAN ALLEGIANCE BENEFIT PLAN MANAGEMENT ALLIED BENEFIT SYSTEMS INC ALLSAVERS LIFE INSURANCE COMPANY ALTERNATIVE INSURANCE RESOURCES INC ALTIUS HEALTH PLAN AMBETTER AMERIBEN AMERICAN FAMILY LIFE ASSURANCE CO AFLAC AMERICAN INCOME LIFE INSURANCE COMPANY AMERICAN NATIONAL INSURANCE COMPANY AMERICAN NATIONAL LIFE INSURANCE COMPANY OF TEXAS AMERICAN NATIONAL LIFE INSURANCE COMPANY OF TEXAS AMERICAN POSTAL WORKERS UNION HEALTH PLAN APWU AMERICAN REPUBLIC INSURANCE AMERICAN RETIREMENT LIFE INSURANCE COMPANY MEDICA AMERICHOICE OF NEW JERSEY AMERIGROUP CORPORATION AMERIHEALTH ADMINISTRATORS AMERIHEALTH CARITAS LOUISIANA AMERIHEALTH CARITAS PENNSYLVANIA AMERITAS ANTARES MANAGEMENT SOLUTIONS ANTHEM VIVITY ARBOR HEALTH PLAN ARISE HEALTH PLAN ARIZONA PHYSICIANS IPA APIPA ASR HEALTH BENEFITS ASSOCIACION DE MAESTROS PUERTO RICO ASURIS NORTHWEST HEALTH AULTCARE AUTOMATED BENEFIT SERVICES AUXIANT AVMED BANKERS LIFE AND CASUALTY BANNER HEALTH BC OF IDAHO BENEFIT MANAGEMENT INC BEST CHOICE HEALTH PLAN BEST LIFE AND HEALTH BETTER HEALTH BETTER HEALTH PLANS UNISON HEALTH PLAN BLUE BENEFIT ADMINISTRATORS OF MASSACHUSETTS BLUE CROSS BLUE SHIELD BLUE SHIELD BLUEGRASS FAMILY HEALTH BMC HEALTHNET BOON GROUP BOSTON MEDICAL CENTER HEALTHNET PLAN BRAVO HEALTH INC BRIDGESPAN BRIDGESTONE AMERICAS INC BRIDGEWAY HEALTH SOLUTIONS BUCKEYE COMMUNITY HEALTH PLAN CALIFORNIA HEALTH AND WELLNESS CALOPTIMA CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPITOL ADMINISTRATORS CAPROCK CARE IMPROVEMENT PLUS CARE MANAGEMENT COMPANY CARE1ST HEALTH PLAN ARIZONA CAREPLUS CAREPLUS HEALTH PLAN CARESOURCE (FHM) CARESOURCE OF INDIANA CARESOURCE OF OHIO CARESOURCE OF WEST VIRGINIA CARITEN HEALTHCARE CDS GROUP HEALTH CELTIC INSURANCE CELTICARE HEALTH PLAN CENCAL CENPATICO BEHAVIORAL HEALTH CENTERLIGHT HEALTHCARE INC CENTRAL BENEFITS CENTRAL CALIFORNIA ALLIANCE FOR HEALTH CENTRAL SENIOR CARE CENTRAL STATES FUND CHAMP VA CHAMPVA/SPINA BIFIDA/CHN OF WOMEN VIETNAM VETS CHCS SERVICES INC CHESAPEAKE NATIONAL LIFE INSURANCE HEALTHMARKETS CHILDRENS MERCY PCN CHP DIRECT CHRISTIAN BROTHERS SERVICES CHRISTIAN BROTHERS SERVICES CIGNA CLAIMS MANAGEMENT SERVICE INC CMFG LIFE INSURANCE COLONIAL PENN LIFE COLORADO ACCESS COMMERCE BENEFITS GROUP COMMUNITY CARE OF OKLAHOMA CONNECTICARE CONSOLIDATED ASSOCIATES RAILROAD COOK CHILDRENS HEALTH PLAN COOPERATIVE BENEFIT ADMINISTRATORS COORDINATED CARE CORESOURCE (FMH) CORESOURCE (MD PA & IL) CORESOURCE LITTLE ROCK CORESOURCE LITTLE ROCK COUNTRY CUPBOARD COUNTRY LIFE INSURANCE COMPANY COVENTRY MISSOURI COX HEALTH PLAN CULINARY HEALTH FUND UNITE HERE HEALTH DAKOTA CARE DAKOTACARE DEAN HEALTH PLAN DEFINITY HEALTH DELAWARE PHYSICIANS CARE DENVER HEALTH MEDICAL PLAN DESERET MUTUAL (DMBA) EBMS EBMS (EMPLOYEE BENEFIT MANAGEMENT SERVICE) EMBLEM HEALTH EMPLOYERS HEALTH COALITION (HEALTHSCOPE) EPIC LIFE INSURANCE ESSENCE HEALTHCARE EVANGELICAL COMMUNITY HOSPITAL EVERCARE EVERENCE FINANCIAL EVERGREEN HEALTH CO-OP FALLON COMMUNITY HEALTH PLAN FAMILYCARE FEDERATED INSURANCE COMPANY FIDELIS CARE NEW YORK FIDELIS CARE NEW YORK FIDELIS SECURECARE OF MICHIGAN FIRST AMERITAS OF NEW YORK FIRST MEDICAL NETWORK FIRST UNITED AMERICAN INSURANCE COMPANY FLORIDA HEALTH CARE PLANS FLORIDA HOSPITAL HEALTHCARE SYSTEM FREEDOM BLUE FRESENIUS HEALTH PARTNERS GATEWAY HEALTH PLAN GEISINGER HEALTH PLAN GEISINGER HEALTH PLAN-GOLD GEMCARE GHI - GROUP HEALTH INC GLOBE LIFE AND ACCIDENT INSURANCE COMPANY GOLDEN RULE GOLDEN RULE INSURANCE GOLDEN TRIANGLE PHYSICIAN ALLIANCE GOVERNMENT EMPLOYEES HEALTH ASSOCIATION (GEHA) GOVERNMENT EMPLOYEES HOSPITAL ASSOCIATION GRANITE STATE HEALTH PLAN GROUP AND PENSION ADMINISTRATORS GROUP HEALTH COOPERATIVE GROUP PRACTICE AFFILIATES HARKEN HEALTH HARMONY HEALTH PLAN HARVARD PILGRIM HEALTHCARE HEALTH ALLIANCE PLAN HEALTH CHOICE OF ARIZONA HEALTH FIRST HEALTH PLAN HEALTH FIRST INSURANCE HEALTH NET HEALTH NEW ENGLAND HEALTH PLAN OF SAN MATEO HEALTH PLAN OF UPPER OHIO VALLEY HEALTH SERVICES FOR CHILDREN WITH SPECIAL NEEDS HEALTH SHARE OF OREGON HEALTHCARE SOLUTIONS GROUP HEALTHE EXCHANGE HEALTHEASE HEALTHEASE KIDS HEALTHEZ HEALTHFIRST OF NEW JERSEY HEALTHNOW HEALTHPARTNERS OF MN HEALTHPLAN OF NEVADA HEALTHPLAN SERVICES CELTIC INSURANCE CO HEALTHPLAN SERVICES FIRST HEALTH LIFE HEALTHPLAN SERVICES METLIFE INSURANCE CO HEALTHPLAN SERVICES PHYSICIANS MUTUAL HEALTHPLAN SERVICES TRUSTMARK LIFE HEALTHPLANS INC HEALTHPLUS OF MICHIGAN HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEALTHSPRING HEALTHSPRINGS HEALTHY TEXAS HERITAGE PHYSICIAN NETWORK (HOUSTON) HIGHMARK HEALTH INSURANCE COMPANY HIPNY HMA - HEALTH MANAGMENT ADMIN HOME STATE HEALTH PLAN HOMETOWN HEALTH HORIZON NEW JERSEY HEALTH HUMANA HUMANA CARESOURCE IBEW LOCAL 508 HEALTH PLAN IBM INSURANCE OUTSOURCING SERVICES IDEAL LIFE INSURANCE ILLINICARE HEALTH PLAN INDEPENDENCE ADMINISTRATORS INDEPENDENT HEALTH INLAND EMPIRE HEALTH Inland Empire Health Plan INLAND EMPIRE HEALTH PLAN CALIFORNIA INTEGRATED MENTAL HEALTH SERVICES INTER VALLEY HEALTH PLAN INTER VALLEY HEALTH PLAN CALIFORNIA ISLAND HOME INSURANCE J F MALLOY AND ASSOCIATES JMH HEALTH PLAN FLORIDA JOHN ALDEN LIFE INSURANCE COMPANY ASSURANT HEALTH JOHNS HOPKINS HEALTHCARE KAISER FOUNDATION HEALTH PLAN OF HAWAII KAISER FOUNDATION HEALTH PLAN OF HAWAII KAISER FOUNDATION HEALTH PLAN OF THE MID ATLANTIC KAISER FOUNDATION OF CO KAISER FOUNDATION OF MID ATLANTIC KAISER FOUNDATION OF NW KAISER FOUNDATION OF OH KAISER PERMANENTE - KPIC KAISER PERMANENTE NORTHERN CALIFORNIA KAISER PERMANENTE OF GEORGIA KAISER PERMANENTE SOUTHERN CALIFORNIA KATY MEDICAL GROUP KEMPTON COMPANY KEY BENEFIT ADMINISTRATORS (INDIANAPOLIS IN) KEYSTONE HEALTH PLAN EAST KEYSTONE MERCY HEALTH PLAN KITSAP PHYSICIAN SERVICES KSKJ LIFE LEON MEDICAL CENTERS HEALTH PLAN LIBERTY NATIONAL LIFE INSURANCE COMPANY LIFETIME BENEFIT SOLUTIONS LIFEWISE ARIZONA LIFEWISE HEALTH PLAN OF OREGON LIFEWISE HEALTH PLAN OF WASHINGTON LINCOLN HERITAGE LOOMIS COMPANY LOUISIANA HEALTH EXCHANGE LOUISIANA HEALTHCARE CONNECTIONS LOVELACE HEALTH PLAN MAGELLAN HEALTH SERVICES MAGNACARE MAGNOLIA HEALTH PLAN MAIL HANDLERS BENEFIT PLAN MAMSI HEALTH PLAN MANAGED CARE OF AMERICA MANAGED HEALTH SERVICES IN MANAGED HEALTH SERVICES INDIANA MANAGED HEALTH SERVICES WI MANAGED HEALTH SERVICES WISCONSIN MARICOPA CARE ADVANTAGE ARIZONA MARICOPA HEALTH PLAN ARIZONA MDWISE HOOSIER ALLIANCE MED-PAY INC MEDBEN MEDCOST BENEFIT SERVICES MEDICA MEDICA INSURANCE MEDICAID ALASKA MEDICAID CONNECTICUT MEDICAID FLORIDA MEDICAID GEORGIA MEDICAID HAWAII MEDICAID IDAHO MEDICAID ILLINOIS MEDICAID INDIANA MEDICAID KANSAS MEDICAID KENTUCKY MEDICAID MICHIGAN MEDICAID NEBRASKA MEDICAID NEW JERSEY MEDICAID NEW MEXICO MEDICAID NEWYORK MEDICAID NORTH CAROLINA MEDICAID OHIO MEDICAID OKLAHOMA MEDICAID PENNSYLVANIA MEDICAID PUERTO RICO MEDICAID SOUTH DAKOTA MEDICAID TENNESSEE MEDICAL ASSOCIATES HEALTH PLAN - HEALTH CHOICES MEDICAL MUTUAL MEDICO INSURANCE COMPANY MEDIGOLD HEALTH PLANS MEDSTAR FAMILY CHOICE MEDSTAR HEALTH PLAN MEGA LIFE AND HEALTH INSURANCE COMPANY HEALTHMARKETS MEGA LIFE OKLAHOMA CITY MEMORIAL CLINICAL ASSOCIATES MERCY CARE PLAN (ARIZONA) MERIDIAN HEALTH PLAN OF ILLINOIS MERITAIN HEALTH MHNET BEHAVIORAL HEALTH MI CHILD MICHIGAN MICHILD MISSISSIPPI CHILDRENS HEALTH INSURANCE PROGRAM MISSISSIPPI SEHP STATE EMPLOYEE HEALTH PLAN MMSI MOLINA HEALTHCARE OF CALIFORNIA MOLINA HEALTHCARE OF FLORIDA MOLINA HEALTHCARE OF ILLINOIS MOLINA HEALTHCARE OF MICHIGAN MOLINA HEALTHCARE OF MISSOURI MOLINA HEALTHCARE OF NEW MEXICO MOLINA HEALTHCARE OF OHIO MOLINA HEALTHCARE OF SOUTH CAROLINA MOLINA HEALTHCARE OF TEXAS MOLINA HEALTHCARE OF UTAH MOLINA HEALTHCARE OF WASHINGTON MOLINA HEALTHCARE OF WISCONSIN MORRIS ASSOCIATES MOUNTAIN STATE MUNICIPAL HEALTH BENEFIT FUND MUTUAL HEALTH SERVICES MUTUAL OF OMAHA MVP HEALTH PLAN OF NY NATIONAL ASSOCIATION OF LETTER CARRIERS NATIONAL MEDICARE CMS NATIONWIDE SPECIALTY HEALTH FKA NATIONWIDE HEALTH PLAN NEHEN - 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Select Immediately 2 Days 1 Week 2 Weeks 1 Month Other What Type Of Treatment You Are Looking For: Select Inpatient Outpatient Detox Long term Treatment LGBTQ or Gender Specific Virtual Mental Illness: Select YES No UNKNOWN Have Health Insurance: Select YES No Select Insurance Company 1199 National Benefit Fund (SEUI) AARP ABSOLUTE TOTAL CARE ADMINISTRATIVE SERVICES INC AETNA AFFINITY HEALTH PLAN AFTRA HEALTH FUND ALAMEDA ALLIANCE HEALTH PLAN ALLEGIANCE BENEFIT PLAN MANAGEMENT ALLIED BENEFIT SYSTEMS INC ALLSAVERS LIFE INSURANCE COMPANY ALTERNATIVE INSURANCE RESOURCES INC ALTIUS HEALTH PLAN AMBETTER AMERIBEN AMERICAN FAMILY LIFE ASSURANCE CO AFLAC AMERICAN INCOME LIFE INSURANCE COMPANY AMERICAN NATIONAL INSURANCE COMPANY AMERICAN NATIONAL LIFE INSURANCE COMPANY OF TEXAS AMERICAN NATIONAL LIFE INSURANCE COMPANY OF TEXAS AMERICAN POSTAL WORKERS UNION HEALTH PLAN APWU AMERICAN REPUBLIC INSURANCE AMERICAN RETIREMENT LIFE INSURANCE COMPANY MEDICA AMERICHOICE OF NEW JERSEY AMERIGROUP CORPORATION AMERIHEALTH ADMINISTRATORS AMERIHEALTH CARITAS LOUISIANA AMERIHEALTH CARITAS PENNSYLVANIA AMERITAS ANTARES MANAGEMENT SOLUTIONS ANTHEM VIVITY ARBOR HEALTH PLAN ARISE HEALTH PLAN ARIZONA PHYSICIANS IPA APIPA ASR HEALTH BENEFITS ASSOCIACION DE MAESTROS PUERTO RICO ASURIS NORTHWEST HEALTH AULTCARE AUTOMATED BENEFIT SERVICES AUXIANT AVMED BANKERS LIFE AND CASUALTY BANNER HEALTH BC OF IDAHO BENEFIT MANAGEMENT INC BEST CHOICE HEALTH PLAN BEST LIFE AND HEALTH BETTER HEALTH BETTER HEALTH PLANS UNISON HEALTH PLAN BLUE BENEFIT ADMINISTRATORS OF MASSACHUSETTS BLUE CROSS BLUE SHIELD BLUE SHIELD BLUEGRASS FAMILY HEALTH BMC HEALTHNET BOON GROUP BOSTON MEDICAL CENTER HEALTHNET PLAN BRAVO HEALTH INC BRIDGESPAN BRIDGESTONE AMERICAS INC BRIDGEWAY HEALTH SOLUTIONS BUCKEYE COMMUNITY HEALTH PLAN CALIFORNIA HEALTH AND WELLNESS CALOPTIMA CAPITAL DISTRICT PHYSICIANS HEALTH PLAN (CDPHP) CAPITOL ADMINISTRATORS CAPROCK CARE IMPROVEMENT PLUS CARE MANAGEMENT COMPANY CARE1ST HEALTH PLAN ARIZONA CAREPLUS CAREPLUS HEALTH PLAN CARESOURCE (FHM) CARESOURCE OF INDIANA CARESOURCE OF OHIO CARESOURCE OF WEST VIRGINIA CARITEN HEALTHCARE CDS GROUP HEALTH CELTIC INSURANCE CELTICARE HEALTH PLAN CENCAL CENPATICO BEHAVIORAL HEALTH CENTERLIGHT HEALTHCARE INC CENTRAL BENEFITS CENTRAL CALIFORNIA ALLIANCE FOR HEALTH CENTRAL SENIOR CARE CENTRAL STATES FUND CHAMP VA CHAMPVA/SPINA BIFIDA/CHN OF WOMEN VIETNAM VETS CHCS SERVICES INC CHESAPEAKE NATIONAL LIFE INSURANCE HEALTHMARKETS CHILDRENS MERCY PCN CHP DIRECT CHRISTIAN BROTHERS SERVICES CHRISTIAN BROTHERS SERVICES CIGNA CLAIMS MANAGEMENT SERVICE INC CMFG LIFE INSURANCE COLONIAL PENN LIFE COLORADO ACCESS COMMERCE BENEFITS GROUP COMMUNITY CARE OF OKLAHOMA CONNECTICARE CONSOLIDATED ASSOCIATES RAILROAD COOK CHILDRENS HEALTH PLAN COOPERATIVE BENEFIT ADMINISTRATORS COORDINATED CARE CORESOURCE (FMH) CORESOURCE (MD PA & IL) CORESOURCE LITTLE ROCK CORESOURCE LITTLE ROCK COUNTRY CUPBOARD COUNTRY LIFE INSURANCE COMPANY COVENTRY MISSOURI COX HEALTH PLAN CULINARY HEALTH FUND UNITE HERE HEALTH DAKOTA CARE DAKOTACARE DEAN HEALTH PLAN DEFINITY HEALTH DELAWARE PHYSICIANS CARE DENVER HEALTH MEDICAL PLAN DESERET MUTUAL (DMBA) EBMS EBMS (EMPLOYEE BENEFIT MANAGEMENT SERVICE) EMBLEM HEALTH EMPLOYERS HEALTH COALITION (HEALTHSCOPE) EPIC LIFE INSURANCE ESSENCE HEALTHCARE EVANGELICAL COMMUNITY HOSPITAL EVERCARE EVERENCE FINANCIAL EVERGREEN HEALTH CO-OP FALLON COMMUNITY HEALTH PLAN FAMILYCARE FEDERATED INSURANCE COMPANY FIDELIS CARE NEW YORK FIDELIS CARE NEW YORK FIDELIS SECURECARE OF MICHIGAN FIRST AMERITAS OF NEW YORK FIRST MEDICAL NETWORK FIRST UNITED AMERICAN INSURANCE COMPANY FLORIDA HEALTH CARE PLANS FLORIDA HOSPITAL HEALTHCARE SYSTEM FREEDOM BLUE FRESENIUS HEALTH PARTNERS GATEWAY HEALTH PLAN GEISINGER HEALTH PLAN GEISINGER HEALTH PLAN-GOLD GEMCARE GHI - GROUP HEALTH INC GLOBE LIFE AND ACCIDENT INSURANCE COMPANY GOLDEN RULE GOLDEN RULE INSURANCE GOLDEN TRIANGLE PHYSICIAN ALLIANCE GOVERNMENT EMPLOYEES HEALTH ASSOCIATION (GEHA) GOVERNMENT EMPLOYEES HOSPITAL ASSOCIATION GRANITE STATE HEALTH PLAN GROUP AND PENSION ADMINISTRATORS GROUP HEALTH COOPERATIVE GROUP PRACTICE AFFILIATES HARKEN HEALTH HARMONY HEALTH PLAN HARVARD PILGRIM HEALTHCARE HEALTH ALLIANCE PLAN HEALTH CHOICE OF ARIZONA HEALTH FIRST HEALTH PLAN HEALTH FIRST INSURANCE HEALTH NET HEALTH NEW ENGLAND HEALTH PLAN OF SAN MATEO HEALTH PLAN OF UPPER OHIO VALLEY HEALTH SERVICES FOR CHILDREN WITH SPECIAL NEEDS HEALTH SHARE OF OREGON HEALTHCARE SOLUTIONS GROUP HEALTHE EXCHANGE HEALTHEASE HEALTHEASE KIDS HEALTHEZ HEALTHFIRST OF NEW JERSEY HEALTHNOW HEALTHPARTNERS OF MN HEALTHPLAN OF NEVADA HEALTHPLAN SERVICES CELTIC INSURANCE CO HEALTHPLAN SERVICES FIRST HEALTH LIFE HEALTHPLAN SERVICES METLIFE INSURANCE CO HEALTHPLAN SERVICES PHYSICIANS MUTUAL HEALTHPLAN SERVICES TRUSTMARK LIFE HEALTHPLANS INC HEALTHPLUS OF MICHIGAN HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEALTHSPRING HEALTHSPRINGS HEALTHY TEXAS HERITAGE PHYSICIAN NETWORK (HOUSTON) HIGHMARK HEALTH INSURANCE COMPANY HIPNY HMA - 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