Am I Covered?

Name: Summer House Detox Center
Address: 13550 Memorial Highway, Miami, FL, 33161
Telephone: 800-719-1090
Price range: $$$

Please fill out our secure form so we can verify benefits with your insurance company. If you fill the form out during normal business hours, we will contact you the same day. If you fill this out after-hours we will contact you the next morning.

How did you hear about us?*
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone
Date of Birth of Patient*
MM slash DD slash YYYY
Social Security Number of Patient (Format: ###-##-####)*
Name On Insurance Card*
Name of Insurance Company*
Policy Number*
Insurance Group Name or Number?
nsurance Company Phone Number*
Are You Drinking Alcohol?
- Yes
- No
Are you taking Drugs?
- Yes
- No
Are you taking Medications?
- Yes
- No
How is your Health? Please explain any health issues.
How Should We Contact You?*
- Phone
- Email
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Privacy Policy: This information is private and will never be shared with any other organizations.

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