Facility Name

 Address

Ph #  
Fax #
E-mail 

SPECIALTY PROGRAMS *
 
* NOTE: Specialty Programs examples: Eating Disorder Program, Closed Door Facility, Sexual Dysfunction Treatment, etc.

DIAGNOSES TREATED **

** NOTE: Diagnoses Treated - list primary diagnoses treated, especially unusual diagnoses. This list is primarily for use by Military Health Benefits Advisors and other referral agents looking for facilities serving specific diagnostic categories.

CONTACT PERSON FOR ADMISSIONS
Name             ph #
E-mail  

CONTACT PERSON FOR CONTRACTING
Name             ph #
E-mail  

Web Site Address  

Other information you would like to include in your listing

 

Sections in which listing is to appear:
(Check all that apply)

 
Optional - Please specify other states in which listing is to appear (i.e.: neighboring states).

Check box if your facility is a Tricare Designated Preferred Provider