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.

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Please complete the form below

Name *
Name
Home Address *
Home Address
Enter the name of your insurance company, type or plan below:
Please let us know your relationship to the insured:
How Did You Hear About Us? *
Please choose all the apply:

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.