Insurance Verification Form

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Verify Your Insurance

Welcome to Fountain Hills Recovery. Please fill out the form below to begin the insurance verification process. As soon as we receive it, a member of our Admissions Team will contact you by phone to discuss your treatment options.

PLEASE COMPLETE THE FORM BELOW

Please be aware that Fountain Hills Recovery is an Out of Network Facility. We are unable to accept AHCCCS, Medicare or Medicaid policies.

"*" indicates required fields

Client Name*

Client DOB*

Insurance Policy Information

Policy Holder Legal Name*

Policy Holder DOB*

Insurance Company Name, Type, or Plan*

Insurance Company Phone*

Member ID*

Group Number*

Group/Employer Name

Policy Holder Address*

Street Address City ZIP / Postal Code

Policy Holder Email*

Policy Holder Phone*

Is this the primary insurance policy?

Yes

Consent*

By checking this box, I agree to Fountain Hills Recovery Privacy Policy and Communications Disclaimers. Click here to read in full.*

Name

This field is for validation purposes and should be left unchanged.

Fountain Hills Recovery is here to help.

Call us now at (800) 715-2004 to begin your journey towards a life free from the grips of substance abuse and behavioral health disorders.

Insurance Verification Form

Verify Your Insurance

PLEASE COMPLETE THE FORM BELOW

Insurance Policy Information

Fountain Hills Recovery is here to help.

We're Here To Help