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Elemental Health Network Application

Elemental Health wants to partner with strong and ethical providers to help its patients continue progress made within our Intensive Outpatient Program, in the comfort of their community.


Please provide us as much information as possible in order to provide it to our patients prior to graduating from our program.


If any information changes throughout the year, please email us the new changes (insurances, location, availability etc.) to connect@elementalhealthbr.com.

* Full Name
0/50
* Credentials
0/50
* Company Name
0/50
* Phone Number
0/50
Fax Number
0/50
* Address
0/50
* Any affiliations with other entities in the community?
0/500
* Population demographic
0/250
Which diagnosis do you like to treat? Any specialties?
0/500
* What is the time frame to schedule initial appointment?
0/250
* When can you see patients?
* Which insurances are you contracted with?
0/250
* How does Elemental Health refer to you?
0/500
Anything else Elemental Health should know about your practice?
0/500
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