Addiction Marketing Specialists Preferred Provider
To ensure the accuracy of your listings for your facility, please be as detailed as possible when filling out this questioner.
* Required
Email address
*
Name Of Facility
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Full Address
*
Regions Served
Website Address
*
Levels of Care
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Inpatient (Hospital) Detox
Residential Detox (DTX)
Residential Treatment (RTC)
Partial Hospitalization (PHP)
Intensive Outpatient (IOP)
Outpatient Treatment (OP)
Outpatient Detox
Sober Living
Suboxone/Methadone Provider
In-Network Contracts
*
Insurances Accepted
*
Insurances Not Accepted
Clinical Specialties
Limitations(What do you refer out?)
*
Any additional information you'd like us to convey before making a referral ?
Please provide the details on your referral process & acceptance lead time
With our clients permission may we email you demographic and insurance information?
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Yes
No
Primary Contact First & Last Name
*
Primary Contact Phone
*
Intake/Admissions Contact
*
Intake/Admissions Email
*
A copy of your responses will be emailed to the address you provided.
