Application for Services
Please complete this form if your organization in interested is hosting an Ideal Option satellite kiosk for medication-assisted treatment services. Please note services are only available in WA, OR, ID, MT, NM, MN, MD, ND and AR.
Street Address Line 2
Please tell us why you are interested in offering onsite MAT services.
How many individuals would you estimate are in need of MAT services at your organization?
10 - 20
20 - 30
30 - 40
Please respond to the following questions:
Do you have a private room available?
Is there an ADA restroom available?
Are you able to collect urine specimens?
Can you accommodate a lockbox for specimens?
Do you have wi-fi strong enough for video calls?
Do you have a computer workstation available?
Is your building zoned for medical use?
Can you verify patient insurance coverage?
Can your staff assist with patient intake?
Is there anything else you'd like to share with us?
Should be Empty: