We are sorry, but at this time we are unable to accept any insurance.

Information Starts Here:

1: To Start the process: Please fill out the Enrollment request form below. We are being delayed due to phone calls asking questions that are answered in the Enrollment Packet.  

2: When we receive your request for Enrollment you will be sent an Enrollment Packet within 1 - 7 days.

3: READ the Enrollment Packet!!

4: If out the enrollment packet on screen, save and submit. We only take the original PDF format. No images of any type. The file should be less than 15MB.

5: Your returned Enrollment Packet will be reviewed for completeness by Pre-Enrollment. Once accepted you will be sent an email by Pre-enrollment when your application is reviewed by Medical. 

6: Not all cases are accepted. If medically accepted, you will be called by Enrollment to start the process of ordering your labs.   

7: Those in states without a Millennium-TBI Network provider will need to locate someone to prescribe any medication.  We have Florida, Texas, and California licensing. 

8: Please understand that calling and emailing us will delay everyone getting enrolled. For this reason we have provided extensive information in our Enrollment Packet so please read them.  

 
 

There is no fee to Enroll in a Program or to fill-out an Enrollment packet.  

Please try not to call the office to obtain information on enrollment and our program. Once you have placed an enrollment request you will be sent comprehensive information along with an enrollment application.  Each phone call decreases our time and ability to provide our services.


If your enrollment request is incomplete, it will be rejected so please check your form before submitting it. Thank you.  

U.S.A. Patient Enrollment Request

We are experienceing a heavy request for Enrollment. Please do not place more than one request. We are running with a 3-4 week delay.

*State :
 * required
*Referred by:
*I am
Branch:
*My Case is
*LASTname:
 * required
*FIRSTname:
 * required
Gender:
*Date of Birth:
 * required
*Email:
 * required
*Telephone:
 * required
*City:
 * required
* ZIP:
 * required
Country:

DO NOT submit multiple requests they will ALL be deleted from this system.
Incomplete request forms will be rejected. Verify that you have answered every line. 

A reading List for you:

     
 

2019 Summary Report on the Millennium TBI Program