If you are submitting this form on behalf of a loved one, please provide your contact information only.
Your information is securely transferred and will remain confidential.
If you have government insurance (Medicare/Medicaid/Tricare), we first need to speak with the case manager at your insurance company. Rather than completing this form, please have your case manager contact us at 312-298-9936.
Learn about additional treatment options and resources that you may be eligible for.
If you are not currently insured, please learn about additional treatment options and resources that you may be eligible for here rather than submitting this form, or call us at 1-877-304-1218 .