Someone Else Will Be Paying

If someone else will be paying for your treatment, please give us their contact information below and we will contact them for you.  By submitting this information, you give us permission to contact the person below for the purpose of arranging payment.

Payer's Name *
Payer's Name
Name of person responsible for payment
Phone *
Phone
I give Recovery Help permission to contact the payer above to discuss payment of my program. *