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If you work with a non-profit agency that helps individuals find substance use disorder treatment and you have an indigent patient requesting treatment, please complete the form in its entirety and submit it electronically.  All coverage requests are reviewed within 48 hours of receipt and you will receive a direct response regarding the ability of the Foundation of Recovery to provide financial assistance to the individual.  All financial aid is directly paid to the healthcare agency or treatment provider and not paid to the individual or the requestor.  Thank you.

Coverage Request Form

  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • REFERRAL CENTER INFORMATION