Contact Me

Wade Gale
Executive Marketing Director
Cell: 801-455-0075
wadegale@unitedrecoveryfront.com
www.unitedrecoveryfront.com

Information I need to help: I do the searching for you to get you in contact with an accredited facility.

(this is not a guarantee of immediate placement, as there may be waitlists for bed availability.  What we will do is contact the  facilities for you to see if they have availability.  Our network only works with accredited facilities in the state of Utah.)

United Recovery Front Patient Form 2023

Patient Information Form

Patient Name:_________________________________________________________ 

Type of Treatment: Residential:____ Detox:_____ Out Patient:_____ Therapy:_____ 

Patient Date of Birth:_____/_____/__________

Patient Contact Number:_____-_____-________
 Patient Code if in hospital:_____________
 Patient estimated discharge date from hospital:_____/_____/__________ 

Patient Insurance Provider:__________________________________________ 

Insurance Policy #:________________________
 Insurance Group #:________________________
 Patient Primary Contact Name:_______________________________________ 

Patient Primary Contact Number:_____-_____-__________ 


Signature:_______________________________________________________

Wade Gale
 United Recovery Front
 C: 801-455-0075 wadegale@unitedrecoveryfront.com

All information provided to United Recovery Front is confidential and is used only for the purpose of finding a treatment provider for a patient. United Recovery Front does not sell any of the collected information for any purpose. By filling out this form, you authorize URF to act on your behalf to contact treatment facilities/hospitals/programs to find a suitable treatment option. URF abides by all Federal and States laws in concern to your privacy.

 

If you are an EAP, Private Individual or a private company looking to utilize our services for free...Please contact us by email.

The form below is for individuals.  

Businesses please call me @ 801-455-0075 Wade Gale or email me at wadegale@unitedrecoveryfront.com

Information you need to know