Patient Deposit - Brookdale Premier Addiction Recovery

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Deposit Ancillary Funds for a Brookdale Patient

Name: Brookdale Recovery
Address: 2455 Back Mountain Rd, Scotrun, Pennsylvania, 18355, USA
Telephone: 1 (855) 575-1292

Upon submission, you will receive a confirmation of your deposit via email. Our intake department will use your contact information provided below for any account-related questions.

Please Choose Your Relationship to the Patient at Brookdale *

I am the Patient
Parent
Family Member
Loved One

Please select how the authorized credit card user is related to the patient.

Your Name *

First

Last

Your Email *

Your Phone *

Patient's Name *

First

Last

Patient's D.O.B *

Secure form - we ask for D.O.B to ensure that your deposit is credited to the correct patient. This information will not be shared or used for any other purpose.

Patient's Email *

We will send an email confirmation to the patient regarding your deposit today.

Deposit Amount *

Please select the amount to be charged & deposited today.

Which Account Should We Credit?

Store
Family Program

Please select one. The amount you deposit today will be credited to the account you select here.

Credit Card Details

Credit Card Type

Amex
Discover
Mastercard
Visa

Name on Card *

First

Last

Credit Card # *

Credit Card Expiration Date *

CCV # *

Credit Card Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Billing Email *

Confirm Email

Billing Phone *

*We respect your privacy. Information required for verification purposes.

Comments

You will receive an email confirmation after clicking "submit" with details of your deposit.

Email *

Name *

First

Last

1 (855) 575-1292

[email protected]

https://brookdalerecovery.com/verify-your-insurance-benefits/

2455 Back Mountain Rd., Scotrun, PA 18355

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