Admission Form

Address: 800 Tydings Lane, Havre de Grace, Maryland, 21078, US
Telephone: (800) 799-4673

Ashley’s admissions staff is here for you 365 days a year. 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*
First name of form submitter Last name of form submitter
Relationship to Patient*
Email Address*
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?*
Patient Information
Patient Name*
First Name of Patient Last Name of Patient
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Marital Status
Patient Street Address
Street Address City State / Province / Region ZIP / Postal Code
Please Indicate Method of Payment
Cash amounts over $10,000 must be reported to the IRS
Who Will Be the Guarantor of the Account?
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*
Insurance Company Phone Number*
Subscriber Name*
Subscriber Date of Birth*
Relationship of subscriber to patient:*
Name of subscriber employer:*
Member ID number:*
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Admission Form

General Information

Patient Information

Insurance Information

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