Apply to place clients with NexxSteps RS

For treatment programs and service agencies placing clients at our Phoenix residence. Tell us who you are, how to reach you at any hour, and what your program bills under. A NexxSteps operator reviews every application. This form collects no client information.

Your organization

Legal company nameDoing business as (optional)

Person signingTheir position in the company

Signer emailSigner phone

Where we reach you

Street addressSuite / unit (optional)

CityStateZIP

Main phoneMain email

24-hour contact

Who we call about an issue with one of your clients — including the written notice owed within 24 hours if a client is removed. Someone reachable outside business hours.

Name24-hour phone

Alternate phoneEmail

Treatment program & insurance billing

What your program provides and the identifiers you bill under.

Levels of care provided

Outpatient (OP)Intensive Outpatient (IOP)Partial Hospitalization (PHP)Residential / inpatientWithdrawal management (detox)Medication-assisted treatment (MAT)

Organization NPI (Type 2)Tax ID / EINTaxonomy code

State license numberLicense expiresAHCCCS / Medicaid ID

AccreditationAccreditation expires

Insurance networks you're contracted with

Billing contactBilling contact email

Certificate of insurance

Section 4 of the agreement: general liability of $1,000,000 per occurrence and $4,000,000 aggregate, with NexxstepsRS, LLC and the Facility named as additional insured. We need this before you can place anyone — a NexxSteps operator verifies the certificate against what you enter here.

CarrierPolicy numberPolicy expires

Per occurrence ($)Aggregate ($)

NexxstepsRS, LLC and the Facility are named as additional insured on this policy.

Anything else we should know (optional)

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