Insurance Verification Form

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.

Client Name *
Client Name
Please provide full legal name of insurance policy holder here.
Please indicate the date of birth of the insurance policy holder here.
Enter the name of your insurance company, type or plan below:
Please provide the insurance policy Member ID here.
Please provide insurance policy Group Number here.
Please indicate the Group/Employer Name here (if applicable).
Please indicate whether this is the primary insurance policy.

This is a secure form. Your private information is always kept confidential and will not be used or shared for any reason other than to communicate privately with your insurance company and the insured.