Admissions Inquiry

Ashley’s admissions staff is here for you.

We work hard every day to make your admissions process as easy and quick as possible. Have peace of mind knowing that your personal information will always be kept confidential. Our committed team is prepared to guide you through every stage of the process.

General Information

Name(Required)

First name of form submitter Last name of form submitter

Relationship to Patient(Required)

Email Address(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

(Only list the numbers that we can use to contact you) If you would like to contact us instead, do not leave your phone numbers. Please contact our Admissions Department: 800-799-4673 x213.

How did you hear about Ashley Addiction Treatment?(Required)

Patient Information

Patient Name(Required)

First Name of Patient Last Name of Patient

Patient Date of Birth(Required)

Marital Status

Patient Street Address

Street Address City State / Province / Region ZIP / Postal Code

Insurance Information

If you would like Ashley to verify your insurance plan benefits, please provide your medical / mental health insurance information below. All information is required. On occasion, more information is required to verify insurance benefits and eligibility. All information below is required in order for Ashley to verify insurance plan benefits.

Insurance Company Name(Required)

Insurance Company Phone Number(Required)

Subscriber Name(Required)

Subscriber Date of Birth(Required)

Relationship of subscriber to patient:(Required)

Name of subscriber employer:(Required)

Member ID number:(Required)