Fillable AHCCCS - Nurse Midwife Provider Type Profile

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AHCCCS - Nurse Midwife Provider Type Profile

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PROVIDER TYPE PROFILE
PROVIDER
TYPE
09
NURSE-MIDWIFE (CNM)
REIMBURSE-
MENT TYPE
02
FEE FOR SERVICE
EFFECTIVE 10-01-87
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY
01
MEDICINE
BOARD OF NURSING
MANDATORY
MANDATORY
OPTIONAL
02
SURGERY
OPTIONAL
08
EPSDT
OPTIONAL
09
PHARMACY
DRUG ENFORCEMENT AGENCY
OPTIONAL
12
PATHOLOGY AND LAB
OPTIONAL
13
RADIOLOGY
OPTIONAL
30
Home Health Nurse Service
Effective 01-01-06
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
SPECIAL INSTRUCTIONS: I_______________________________am the sponsoring physician
(Doctor’s Name)
verifying established protocols between_______________________and myself for the management of
patients, including high-risk patients.
_____________________________ __________
(Signature) (Date)
SPECIAL INSTRUCTIONS: The American Society For Coloscopy and Cervical Pathlogy required for
some 59000 series surgical codes and certification as a Surgical First Assistant required for some 56000
and 57000 OB/Delivery and Cesarean codes.
Revised 05/27/08
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AHCCCS - Nurse Midwife Provider Type Profile

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Completed 29 May 2020

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