Become A New Patient
Thank you for considering our programs. We are a provider of services for all PPO insurances. If you are interested in having your PPO insurance benefits verified, please submit the following information for insurance verification. Someone from South Bay connect treatment Center should email or call you with benefits within 72 hours. Thank you.
transportation service in all areas between Culver City and Huntington Beach
Please complete the following form 1 of the 2 following ways:
Thank you for your cooperation and we look forward to meeting you.
Option Submit Online
- Information is being submitted to an email that is a secure, HIPAA compliant email. Data is encrypted in order to ensure confidentiality
- Click on the Online New Client Information Form link and fill in requested information
- Make sure to hit submit
- Online New Patient Information Form
Save first in your own My Documents
- Make changes
- Email Attachment, email@example.com
- This email is a secure, HIPAA compliant email. Data is encrypted in order to ensure confidentiality
Form to be Attached to Email
Patient Information Sheet