PREAUTHOURISATION

PREAUTHOURISATION

Complete this form and our Admissions department will contact you within 30 Minutes to confirm your Medical Aids commitment to paying for, or contributing towards your treatment at
ARC Addiction Recovery Centre

Name :

Surname :

Date of Birth

Tel :

Email :

Medical Aid :

Medical Aid Plan :

Medical Aid Number :

Main members Name :

Main members Surname :

Main members Contact Number :

Main Members Email :

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What type of substance are you using :

How long ago did your drug/alcohol abuse become a problem :

Has your Medical Aid paid for Rehab in the last calendar year :

YES NO

What date would you like to be admitted :