Name

Phone Number

Email Address

Do You Currently Have Health Insurance? Do You Currently Have Health Insurance? YES NO

Great! What Type of Insurance? Great! What Type of Insurance? Healthy Indiana Plan (HIP) Hoosier Care Connect (HCC) Hoosier Healthwise Private Insurance

Would You Like to Learn About Self-Pay Options? Would You Like to Learn About Self-Pay Options? YES NO

Please contact 211 for grant funded treatment options.

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