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Help Me Find a Drug Rehab Center
Dinwiddie, VA. - Self Pay
Jackson Feild Homes is a Drug Abuse Rehab Facility that is located at:
546 Walnut Grove Drive
Jarratt, VA. 23867
If you would like to contact Jackson Feild Homes, you can reach them at 434-634-3217 x3002.
Jackson Feild Homes offers the following treatment services: Dual Diagnosis, HIV / Aids Treatment Services, LGBT Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
River City is a Drug Rehab that is located at:
215 North Market Street
Petersburg, VA. 23803
If you would like to contact River City, you can reach them at 804-230-0999.
River City offers the following treatment services: Outpatient Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance
District 19 Community Services Board is a Substance Abuse Treatment Facility that is located at:
20 West Bank Street
Petersburg, VA. 23803
If you would like to contact District 19 Community Services Board, you can reach them at 804-862-8054.
District 19 Community Services Board offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, HIV / Aids Treatment Services, Senior Rehabs, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
District 19 Substance Abuse Services is a Drug Rehab Facility that is located at:
20 West Bank Street
Petersburg, VA. 23803
If you would like to contact District 19 Substance Abuse Services, you can reach them at 804-862-6410 x3143.
District 19 Substance Abuse Services offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, HIV / Aids Treatment Services, LGBT Rehabs, Senior Rehabs, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Gateway Homes Inc is a Drug Rehabilitation Program that is located at:
11901 Reedy Branch Road
Chesterfield, VA. 23838
If you would like to contact Gateway Homes Inc, you can reach them at 804-767-0292.
Gateway Homes Inc offers the following treatment services: Outpatient Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted
Colonial Heights Counseling Services is a Drug Treatment Center that is located at:
3660 Boulevard
Colonial Heights, VA. 23834
If you would like to contact Colonial Heights Counseling Services, you can reach them at 804-520-7210.
Colonial Heights Counseling Services offers the following treatment services: Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance
District 19 CSB is a Drug and Alcohol Rehabilitation Center that is located at:
3660 Boulevard
Colonial Heights, VA. 23834
If you would like to contact District 19 CSB, you can reach them at 804-520-7210.
District 19 CSB offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Rehabs that Accept Tricare
Hopewell Prince George Counseling Serv is a Drug Addiction Treatment Center that is located at:
4910 Prince George Drive
Prince George, VA. 23875
If you would like to contact Hopewell Prince George Counseling Serv, you can reach them at 804-541-8660.
Hopewell Prince George Counseling Serv offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance
Greensville Emporia Counseling is a Drug Abuse Treatment Program that is located at:
1101 Greensville County Circle
Emporia, VA. 23847
If you would like to contact Greensville Emporia Counseling, you can reach them at 434-348-8900.
Greensville Emporia Counseling offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, HIV / Aids Treatment Services, Senior Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Greensville Emporia Counseling Service is a Drug Abuse Rehab Center that is located at:
1101 Greensville County Circle
Emporia, VA. 23847
If you would like to contact Greensville Emporia Counseling Service, you can reach them at 434-348-8900 x7002.
Greensville Emporia Counseling Service offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment, Dui/Dwi Clients, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Chesterfield Department of is a Drug Rehab Center that is located at:
6801 Lucy Corr Boulevard
Chesterfield, VA. 23832
If you would like to contact Chesterfield Department of, you can reach them at 804-748-1227.
Chesterfield Department of offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Adolescent / Teen Rehab Centers, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
Chesterfield Community Services Board is a Drug and Alcohol Rehab Center that is located at:
6801 Lucy Corr Court
Chesterfield, VA. 23832
If you would like to contact Chesterfield Community Services Board, you can reach them at 804-768-7318.
Chesterfield Community Services Board offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, Senior Rehabs, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
John Randolph Medical Center is a Drug Abuse Treatment Program that is located at:
411 West Randolph Road
Hopewell, VA. 23860
If you would like to contact John Randolph Medical Center, you can reach them at 804-452-3282.
John Randolph Medical Center offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance
Southern Virginia Regional Medical Ctr is a Drug Treatment Service that is located at:
727 North Main Street
Emporia, VA. 23847
If you would like to contact Southern Virginia Regional Medical Ctr, you can reach them at 434-348-4580.
Southern Virginia Regional Medical Ctr offers the following treatment services: Hospital Inpatient Programs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
Southside Treatment Center is a Drug Treatment Service that is located at:
9609 Jefferson Davis Highway
Richmond, VA. 23237
If you would like to contact Southside Treatment Center, you can reach them at 804-275-1116.
Southside Treatment Center offers the following treatment services: Drug and Alcohol Rehab Services, Drug Detox / Alcohol Detoxification, Outpatient Rehabs, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay
Brunswick Behavioral Health Center is a Drug and Alcohol Treatment Center that is located at:
2087 Lawrenceville Plank Road
Lawrenceville, VA. 23868
If you would like to contact Brunswick Behavioral Health Center, you can reach them at 434-848-4121.
Brunswick Behavioral Health Center offers the following treatment services: Outpatient Rehabs, Dual Diagnosis
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
Sussex Counseling Services is a Drug Abuse Rehab Program that is located at:
232 Coppahaunk Avenue
Waverly, VA. 23890
If you would like to contact Sussex Counseling Services, you can reach them at 804-834-2205.
Sussex Counseling Services offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, Senior Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
New Life for Youth Inc is a Drug and Alcohol Rehabilitation Facility that is located at:
2320 Broad Rock Boulevard
Richmond, VA. 23224
If you would like to contact New Life for Youth Inc, you can reach them at 804-230-4485.
New Life for Youth Inc offers the following treatment services: Drug and Alcohol Rehab Services, Group Homes, Residential Long-Term Rehabs (30 Days or More), Women - Treatment Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Rehabs with Payment Assistance
Chippenham Medical Center is a Drug Treatment Center that is located at:
7101 Jahnke Road
Richmond, VA. 23225
If you would like to contact Chippenham Medical Center, you can reach them at 804-323-8846.
Chippenham Medical Center offers the following treatment services: Hospital Inpatient Programs, Dual Diagnosis, Senior Rehabs, Hearing Impaired Rehab Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
Metro Treatment of Virginia LP is a Drug Abuse Rehab Center that is located at:
2217 East Franklin Street
Richmond, VA. 23223
If you would like to contact Metro Treatment of Virginia LP, you can reach them at 804-213-0249.
Metro Treatment of Virginia LP offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Dual Diagnosis, Women - Treatment Services, Men - Substance Abuse Treatment, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay
Self pay is sometimes the only option for many who need rehabilitation inside a drug rehab center for drug use but have zero medical health insurance. It isn't uncommon for someone addicted to alcohol or drugs to not have private medical insurance, as it can be hard to have a drug or alcohol habit going while also sustaining work. Individuals might possibly not have private health care insurance in the first place, but might make too much money to be entitled to Medicaid which may cover some kinds of rehab. When someone does have to self pay for rehab and doesn't have private medical health insurance, it is a good idea to investigate Medicaid to see if they meet the requirements, when they haven't already done this. If they have no other choice but to self pay, individuals in addition to their loved ones can usually produce the resources to purchase rehab some way. Thankfully, many drug and alcohol rehabilitation facilities will work with individuals whose only option is to self pay to make it more possible for them to participate in an excellent drug rehabilitation facility. You can find payment assistance solutions at many alcohol and drug treatment programs that qualified clients can take advantage of.
Dinwiddie Counseling Services
Dinwiddie Counseling Services is a Drug and Alcohol Treatment Facility that is located at:
13900 Courthouse Road
Dinwiddie, VA. 23841
If you would like to contact Dinwiddie Counseling Services, you can reach them at 804-469-3746.
Dinwiddie Counseling Services offers the following treatment services: Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Rehabs that Accept Tricare
13900 Courthouse Road
Dinwiddie, VA. 23841
If you would like to contact Dinwiddie Counseling Services, you can reach them at 804-469-3746.
Dinwiddie Counseling Services offers the following treatment services: Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Rehabs that Accept Tricare
Jackson Feild Homes
14.6 miles from Dinwiddie, Virginia
Jackson Feild Homes is a Drug Abuse Rehab Facility that is located at:
546 Walnut Grove Drive
Jarratt, VA. 23867
If you would like to contact Jackson Feild Homes, you can reach them at 434-634-3217 x3002.
Jackson Feild Homes offers the following treatment services: Dual Diagnosis, HIV / Aids Treatment Services, LGBT Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
River City
14.8 miles from Dinwiddie, Virginia
River City is a Drug Rehab that is located at:
215 North Market Street
Petersburg, VA. 23803
If you would like to contact River City, you can reach them at 804-230-0999.
River City offers the following treatment services: Outpatient Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance
District 19 Community Services Board
14.9 miles from Dinwiddie, Virginia
District 19 Community Services Board is a Substance Abuse Treatment Facility that is located at:
20 West Bank Street
Petersburg, VA. 23803
If you would like to contact District 19 Community Services Board, you can reach them at 804-862-8054.
District 19 Community Services Board offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, HIV / Aids Treatment Services, Senior Rehabs, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
District 19 Substance Abuse Services
14.9 miles from Dinwiddie, Virginia
District 19 Substance Abuse Services is a Drug Rehab Facility that is located at:
20 West Bank Street
Petersburg, VA. 23803
If you would like to contact District 19 Substance Abuse Services, you can reach them at 804-862-6410 x3143.
District 19 Substance Abuse Services offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, HIV / Aids Treatment Services, LGBT Rehabs, Senior Rehabs, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Gateway Homes Inc
17.3 miles from Dinwiddie, Virginia
Gateway Homes Inc is a Drug Rehabilitation Program that is located at:
11901 Reedy Branch Road
Chesterfield, VA. 23838
If you would like to contact Gateway Homes Inc, you can reach them at 804-767-0292.
Gateway Homes Inc offers the following treatment services: Outpatient Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted
Colonial Heights Counseling Services
17.7 miles from Dinwiddie, Virginia
Colonial Heights Counseling Services is a Drug Treatment Center that is located at:
3660 Boulevard
Colonial Heights, VA. 23834
If you would like to contact Colonial Heights Counseling Services, you can reach them at 804-520-7210.
Colonial Heights Counseling Services offers the following treatment services: Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance
District 19 CSB
17.7 miles from Dinwiddie, Virginia
District 19 CSB is a Drug and Alcohol Rehabilitation Center that is located at:
3660 Boulevard
Colonial Heights, VA. 23834
If you would like to contact District 19 CSB, you can reach them at 804-520-7210.
District 19 CSB offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Rehabs that Accept Tricare
Hopewell Prince George Counseling Serv
20.6 miles from Dinwiddie, Virginia
Hopewell Prince George Counseling Serv is a Drug Addiction Treatment Center that is located at:
4910 Prince George Drive
Prince George, VA. 23875
If you would like to contact Hopewell Prince George Counseling Serv, you can reach them at 804-541-8660.
Hopewell Prince George Counseling Serv offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay, Medicaid Accepted, State Insurance
Greensville Emporia Counseling
21.9 miles from Dinwiddie, Virginia
Greensville Emporia Counseling is a Drug Abuse Treatment Program that is located at:
1101 Greensville County Circle
Emporia, VA. 23847
If you would like to contact Greensville Emporia Counseling, you can reach them at 434-348-8900.
Greensville Emporia Counseling offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, HIV / Aids Treatment Services, Senior Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Greensville Emporia Counseling Service
21.9 miles from Dinwiddie, Virginia
Greensville Emporia Counseling Service is a Drug Abuse Rehab Center that is located at:
1101 Greensville County Circle
Emporia, VA. 23847
If you would like to contact Greensville Emporia Counseling Service, you can reach them at 434-348-8900 x7002.
Greensville Emporia Counseling Service offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment, Dui/Dwi Clients, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
Chesterfield Department of
22.8 miles from Dinwiddie, Virginia
Chesterfield Department of is a Drug Rehab Center that is located at:
6801 Lucy Corr Boulevard
Chesterfield, VA. 23832
If you would like to contact Chesterfield Department of, you can reach them at 804-748-1227.
Chesterfield Department of offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Adolescent / Teen Rehab Centers, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
Chesterfield Community Services Board
22.9 miles from Dinwiddie, Virginia
Chesterfield Community Services Board is a Drug and Alcohol Rehab Center that is located at:
6801 Lucy Corr Court
Chesterfield, VA. 23832
If you would like to contact Chesterfield Community Services Board, you can reach them at 804-768-7318.
Chesterfield Community Services Board offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, Senior Rehabs, Criminal Justice Client Rehabs, Hearing Impaired Rehab Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
John Randolph Medical Center
22.9 miles from Dinwiddie, Virginia
John Randolph Medical Center is a Drug Abuse Treatment Program that is located at:
411 West Randolph Road
Hopewell, VA. 23860
If you would like to contact John Randolph Medical Center, you can reach them at 804-452-3282.
John Randolph Medical Center offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance
Southern Virginia Regional Medical Ctr
24.2 miles from Dinwiddie, Virginia
Southern Virginia Regional Medical Ctr is a Drug Treatment Service that is located at:
727 North Main Street
Emporia, VA. 23847
If you would like to contact Southern Virginia Regional Medical Ctr, you can reach them at 434-348-4580.
Southern Virginia Regional Medical Ctr offers the following treatment services: Hospital Inpatient Programs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
Southside Treatment Center
24.6 miles from Dinwiddie, Virginia
Southside Treatment Center is a Drug Treatment Service that is located at:
9609 Jefferson Davis Highway
Richmond, VA. 23237
If you would like to contact Southside Treatment Center, you can reach them at 804-275-1116.
Southside Treatment Center offers the following treatment services: Drug and Alcohol Rehab Services, Drug Detox / Alcohol Detoxification, Outpatient Rehabs, Dual Diagnosis, Rehabs for Expectant Mothers, Women - Treatment Services, Men - Substance Abuse Treatment
Payment forms accepted: Self Pay
Brunswick Behavioral Health Center
24.8 miles from Dinwiddie, Virginia
Brunswick Behavioral Health Center is a Drug and Alcohol Treatment Center that is located at:
2087 Lawrenceville Plank Road
Lawrenceville, VA. 23868
If you would like to contact Brunswick Behavioral Health Center, you can reach them at 434-848-4121.
Brunswick Behavioral Health Center offers the following treatment services: Outpatient Rehabs, Dual Diagnosis
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted
Sussex Counseling Services
25.4 miles from Dinwiddie, Virginia
Sussex Counseling Services is a Drug Abuse Rehab Program that is located at:
232 Coppahaunk Avenue
Waverly, VA. 23890
If you would like to contact Sussex Counseling Services, you can reach them at 804-834-2205.
Sussex Counseling Services offers the following treatment services: Outpatient Rehabs, Dual Diagnosis, Senior Rehabs, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, Private Health Insurance, Rehabs that Accept Tricare, Sliding Fee Scale Accepted, Rehabs with Payment Assistance
New Life for Youth Inc
30.2 miles from Dinwiddie, Virginia
New Life for Youth Inc is a Drug and Alcohol Rehabilitation Facility that is located at:
2320 Broad Rock Boulevard
Richmond, VA. 23224
If you would like to contact New Life for Youth Inc, you can reach them at 804-230-4485.
New Life for Youth Inc offers the following treatment services: Drug and Alcohol Rehab Services, Group Homes, Residential Long-Term Rehabs (30 Days or More), Women - Treatment Services, Spanish Treatment Services
Payment forms accepted: Self Pay, Rehabs with Payment Assistance
Chippenham Medical Center
32 miles from Dinwiddie, Virginia
Chippenham Medical Center is a Drug Treatment Center that is located at:
7101 Jahnke Road
Richmond, VA. 23225
If you would like to contact Chippenham Medical Center, you can reach them at 804-323-8846.
Chippenham Medical Center offers the following treatment services: Hospital Inpatient Programs, Dual Diagnosis, Senior Rehabs, Hearing Impaired Rehab Services
Payment forms accepted: Self Pay, Medicaid Accepted, Medicare Accepted, State Insurance, Private Health Insurance, Rehabs that Accept Tricare
Metro Treatment of Virginia LP
33.8 miles from Dinwiddie, Virginia
Metro Treatment of Virginia LP is a Drug Abuse Rehab Center that is located at:
2217 East Franklin Street
Richmond, VA. 23223
If you would like to contact Metro Treatment of Virginia LP, you can reach them at 804-213-0249.
Metro Treatment of Virginia LP offers the following treatment services: Drug and Alcohol Rehab Services, Outpatient Rehabs, Dual Diagnosis, Women - Treatment Services, Men - Substance Abuse Treatment, Criminal Justice Client Rehabs
Payment forms accepted: Self Pay