Patient Deposit - Brookdale Premier Addiction Recovery

Deposit Ancillary Funds for a Brookdale Patient

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 select how the authorized credit card user is related to the patient.
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.
We will send an email confirmation to the patient regarding your deposit today.
Please select the amount to be charged & deposited today.
Please select one. The amount you deposit today will be credited to the account you select here.

Credit Card Details

*We respect your privacy. Information required for verification purposes.
You will receive an email confirmation after clicking "submit" with details of your deposit.


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