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REVISED 2021 1
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
Directions for completing the AzAHP Practitioner Data Form (AzAHP)
1. CAQH Registration is required (http:/www.caqh.org—for assistance please contact the CAQH HELP DESK at
1-888-599-1771)
2. Your CA
QH application and attestation MUST be up to date and each health plan you are requesting
participation in is authorized to access your data
3. Ensure you provide an ACCURATE CAQH number, or your application may be delayed or rejected
4. PLEASE
TYPE OR PRINT CLEARLY AND COMPLETE THE APPLICATION IN ITS ENTIRETY
a. Additional office locations-please indicate any additional locations on the attached Supplemental Sheet
b. Another Supplemental Sheet is included if necessary, to identify additional Practitioners in Call Group.
They must be contracted with the plan
c. That same Supplemental Sheet has space if necessary, to include all hospital and ambulatory surgery
centers where you have privileges
5. Please c
omplete the Provider Assessment of Cognitive and Physical Disabilities Accommodations tool (pages
4-5). A separate assessment must be completed for each location.
6. The fol
lowing ATTACHMENTS are required to be submitted with the AzAHP FORM SO YOUR REQUEST MAY
BE PROCESSED TIMELY
a. IRS 941 voucher or accurate W-9
b. Copy of your Board Certification (if applicable)
i. Copy of Date of Board Certification Examination
ii. If not Board Certified, please provide documentation of CMEs
c. Copy of your Certificates of Insurance information that include the minimum requirements
i. See page 6 for the Insurance Requirement Checklist
ii. See page 7 and 8 for complete details regarding AHCCCS Insurance Requirements
7. New pro
viders receive written confirmation of their effective date with the health plan(s).
a. Members may not be seen until written confirmation has been received
b. AHCCCS registration is required. You cannot receive payment for services provided without an active
AHCCCS registration
c. Please notify the health plan(s) of your AHCCCS registration if not available at time application was
completed
REVISED 2021 2
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
PLEASE TYPE OR PRINT CLEARLY AND COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST
This form includes Personally Identifiable information (PHI) such as practitioner name, date of birth and SSN and should be sent in a secure manner.
To:
Fax: Phone:
Date:
Post the following items (as applicable) to CAQH-Please check box(es) to indicate items posted:
IRS 941 coupon or accurate W-9 Documentation of board certification or scheduled exam date
Medicaid required insurance certificates as applicable (see page 3 for requirements)
DENTAL PROVIDERS ONLY
General Anesthesia Permit, Conscious Sedation Permit and/or Oral Conscious Sedation Permit
Practitioner’s Name and Degree: (Last) (First) (M.I.) (Degree)
CAQH #
Female Male
DOB:
Tax ID #:
Group Practice Name (DBA) if applicable:
Practitioner’s Effective Date w/Practice
Group Type (check all that apply)
FQHC/RHC IC Multi Spec Other
Practitioner Type:
PCP OBGYN Specialist BH
Dentist Other___________________________________
Lines of Business:
Medicaid Medicare Commercial
Does provider participate in Medicare?
YES NO
Is provider Hospital Based Only?
YES NO
SSN:
Individual NPI#
Organizational NPI#
AHCCCS I.D. #
License #: State: Exp Date:
DEA # State: Exp Date:
If MAT Prescriber XDEA#
State: Exp Date
Primary Practicing Specialty:
Board Certification: YES NO
Date of Exam:
New Graduate:
YES
NO
Graduation/Completion Date (licensed to practice dentistry for the first
time in your career and/or completed post-graduate training for the
first time within the last 6 months.)
Secondary Practicing Specialty:
Board Certification: YES NO
Date of Exam:
Want Contract as PCP? YES NO
Dental Hygienist Affiliated Dentist Name:
Accepting New Patients: YES NO
Patient Age Range:
Patient Gender: Male Female Both
Do you provide services to individuals with special needs/chronic conditions? (check all that
apply)
Physical
Developmental
Behavioral
Emotional
None
Physician Assistant Supervising Physician Name
Do you provide services/accommodations to individuals who have difficulty communicating or
cooperating (i.e.,) those with autism or intellectual disabilities? YES NO
Do you provide services to individuals with mobility limitations (i.e.,
wheelchair bound? YES NO
Do you treat any of the following diagnoses? (check all that apply): Anxiety AHDS EPSDT Depression HIV Substance Abuse None
PCPs and OBS ONLY: Do you provide any of the following services? EPSDT OB None
Do you participate in VFC (Vaccines for Children)?
(PCPs seeing AHCCCS members 18 & < must participate)
YES
NO
VFC PIN CODE:
Do you E-Prescribe? YES NO
Names of Practitioners in Call Group (Must be contracted with plan) Space for
additional names at end of application
Hospital & Ambulatory Surgery Center(s) where practitioner has privileges.
Space for additional names at end of application
REVISED 2021 3
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
BILLING SERVICE
(if applicable)
Name:
Contact:
Address:
Phone:
City:
State:
Zip Code:
Fax:
PAY TO ADDRESS
(all payments sent
to this address)
Address:
City:
State:
Phone:
Fax:
Zip Code:
PRIMARY
ADDRESS
(Physical location
where services
are performed)
Supplemental
sheet attached
for additional
addresses
Address:
City:
State:
Zip Code:
Phone:
Fax:
County:
Provider Office Hours (highlight all that apply)
S M T W TH F S
Time Open: Time Closed:
Special considerations (s) (i.e. closed for lunch, etc)
List Practitioner in Directories at this address? YES NO
OFFICE CONTACT
Name/Title:
Phone:
Fax:
E-mail:
Practice Website Address:
Address:
City:
State:
Zip Code:
CREDENTIALING
CONTACT:
Name:
Phone
Fax:
Email:
Address:
City
State:
Zip Code:
Languages other than English spoken by PRACTITIONER: N/A
Languages other than English spoken by OFFICE STAFF: N/A
Race/Ethnicity: Black/African Hispanic/Latino/Spanish White/Caucasian
Native American/American Indian, Native Hawaiian/Pacific Islander
Asian
Prefer not to disclose
Other (
please add) _______________________________
Describe your Medical Record Keeping System(s) (i.e. EMR, Paper,etc)
Describe your Cost Record Keeping System(s) (i.e. Billing or A/R system)
Electronic Claims Submission? YES NO
Internet Access? YES NO
Is this a minority or female owned business? YES NO
REVISED 2021 4
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
Provider Assessment of Cognitive and Physical Disabilities Accommodations
Please identify what accommodations you provide at each of your practice locations for members with
cognitive or physical disabilities. If accommodations are the same at all locations, on Practice Location
Address, please state ALL. Please, complete a separate Assessment for each location if accommodations
vary.
Practi
ce Location Address:
Accommodation
YES
NO
Comments
Provider/Staff trained to assist individuals with a cognitive
disability, i.e., autism or intellectual disabilities
Provider/Staff trained to assist individuals with a physical
disability, i.e., mobility limitations or wheelchair bound
Flexible appointment times available—sick appointments,
same day appts—please specify
Extended appointment times—before 8 am, after 5pm, Sat
and/or Sunday—please specify
Assistance available to members to fill out forms
In-home and/or community services
Large print materials
Materials in electronic format
Augmentative/Alternative communication devices
TDD capabilities
American Sign Language translator
Signage with Braille and raised tactile text characters at office,
elevator, stairwells and restroom doors mounted 60in from
floor
Visible & Audible alarms – emergency systems
Dimmable Lights
Ramps have non-slip surface material
Railings between 30 & 38in high. On both sides.
Paths are at least 36in wide and free of protruding objects
Cane detectible objects on ground as a warning barrier
Widened doorways (at least 32in clearance)
Offset (swing-clear) hinges
Power assisted or automatic door openers
Door handles no higher than 48in
Lever or loop handles vs knobs
5ft circle or T-shaped space for turning a wheelchair
completely
A clear floor space, 30" X 48" minimum, adjacent to the exam
table and adjoining accessible route make it possible to do a
side transfer
Adjustable height exam table or chair (lowers to 17-19in from
floor)
Positioning and support aids, such as wedges, rolled up
blankets, straps and rails
REVISED 2021 5
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
Accommodation
YES
NO
Comments
Ceiling or floor based patient lift
Gurneys and/or stretchers
Wheelchair accessible scales
Adjustable height radiologic equipment
Handicap parking
Handicap accessible restroom
Access ramps
Accessible by bus
Accessible by Taxis or other similar options (Uber/Lyft)
Accessible by Valley Metro Rail
Provider/Staff has completed cultural competence training
Do you provide Field Clinic services?
(A “clinic” consisting of single specialty health care providers
who travel to health care delivery settings closer to members
and their families than the Multi-
Specialty Interdisciplinary
Clinics (MSICs) to provide a specific set of serv
ices including
evaluation, monitoring, and treatment for CRS-related
conditions on a periodic basis)
Do you provide Virtual Clinic services?
(Integrated services provided in community settings through
the use of innovative strategies for care coordination
such as telemedicine, integrated medical records, and
virtual interdisciplinary treatment team meetings)
REVISED 2021 6
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
INSURANCE REQUIREMENT CHECKLIST
Prior to submitting your insurance information complete this checklist, use it as a tool to address
everything that’s required and send it on top of your insurance document(s). See pages 7 and 8 for
all AHCCCS Insurance Requirements
Commercial General Liability
Professional Liability
ATTACHED NA
ATTACHED
POLICY NUMBER:
POLICY NUMBER:
General Aggregate $2,000,000
Products Ops Aggregate $1,000,000
Personal & Adv. Injury $1,000,000
Damage to Rented Premises $50,000
Each Occurrence $1,000,000
Each Claim $1,000,000
Annual Aggregate $2,000,000
Business Automobile Liability
Workers’ Compensation Liability
ATTACHED N/A
ATTACHED N/A
POLICY NUMBER:
POLICY NUMBER:
Combined Single Limit $1,000,000 Each Accident $1,000,000
Disease – Each Employee $1,000,000
Disease – Policy Limit $1,000,000
Your Certificates of Insurance must include the minimum requirements outlined in the tables
above and the following endorsement, waiver of subrogation and/or SAM language as
applicable.
Endorsement – Required for Commercial General and Business Auto Liability
This policy contains an endorsement that includes the State of Arizona, and its departments, agencies,
boards, commissions, universities, officers, officials, agents, and employees as additional insureds with
respect to liability arising out of the activities performed by the Subcontractor or on behalf of the
Subcontractor or Contractor.
Waiver of Subrogation – Required for Commercial General, Business Auto Liability and Workers’
Compensation Liability
This policy contains a waiver of subrogation endorsement in favor of the State of Arizona, and its
departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for
losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or
Contractor.
Sexual Abuse and Molestation (SAM) – Required for Commercial General Liability or
Professional Liability when providing services to children and/or vulnerable adults
Insurance Certificate(s) must provide the following statement “Sexual Abuse and Molestation coverage
is included” or “Sexual Abuse and Molestation coverage is not excluded”.
• If you are unable to obtain SAM coverage under your General Liability because the insurance
market will not support it, it should be included with the Professional Liability.
REVISED 2021 7
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
AHCCCS Insurance Requirements
This communication outlines the additional insurance requirements and provides examples to assist you.
AHCCCS Insurance Requirements
The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability and
Worker’s Compensation and Employers’ Liability.
Your commercial general liability policy and your business automobile policy (if applicable), need to include an
endorsement (see letter a. below under Commercial General Liability and letter a. below under Business
Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and
letter b. below under Business Automobile Liability) in the Description field of your policy.
Your worker’s compensation and employers’ liability policy requires only the waiver of subrogation language.
Outlined below are the minimum requirements. Policy examples follow
Commercial General Liability – Occurrence Form
Policy should include bodily injury, property damage, personal and advertising injury and broad form contractual
liability coverage. The amounts below are the minimum requirements.
• General Aggregate $2,000,000
• Products – Completed Operations Aggregate $1,000,000
• Personal and Advertising Injury $1,000,000
• Damage to Rented Premises $50,000
• Each Occurrence $1,000,000
a.
The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be named as additional
insureds with respect to liability arising out of the activities performed by or on behalf of the
Contractor." Such additional insured shall be covered to the full limits of liability purchased by the
Subcontractor, even if those limits of liability are in excess of those required by this contract.
b.
Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not
acceptable) in favor of the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising from work performed by or
on behalf of the Subcontractor.
c.
If direct services are provided to children and/or vulnerable adults (as defined by A.R.S §46-
451(A)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM
coverage may be sub-limited to no less than $500,000. The limits may be included within the
General Liability limit, provided by separate endorsement with its own limits. If you are unable to
obtain SAM coverage under your General Liability because the insurance market will not support it,
it should it be included with the Professional Liability.
d.
The following statement must provide on their Certificate(s) of Insurance: “Sexual Abuse
and Molestation coverage is included” or “Sexual Abuse and Molestation coverage is not
excluded.”
REVISED 2021 8
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
Business Automobile Liability
Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the
performance of the services under contract. The amount below is the minimum required.
• Combined Single Limit (CSL) $1,000,000
a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following
additional insured language: “The State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees shall be named as additional
insureds with respect to liability arising out of the activities performed by or on behalf of the
Contractor, involving automobiles owned, leased, hired or borrowed by the Contractor." Such
additional insured shall be covered to the full limits of liability purchased by the Subcontractor, even
if those limits of liability are in excess of those required by this contract.
b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not
acceptable) in favor of the “State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees” for losses arising from work performed by or
on behalf of the Subcontractor.
Worker’s Compensation and Employers’ Liability
• Workers' Compensation Statutory
• Employers' Liability
Each Accident $500,000
Disease – Each Employee $500,000
Disease – Policy Limit $1,000,000
Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor
of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Subcontractor.”
We are requir
ed to verify your adherence to these insurance requirements. We appreciate you submitting Certificates
of Liability with required coverage levels, endorsements and waivers along with the attached checklist
REVISED 2021
9
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
The fax number and phone number for each participating plan is listed in the table below.
If your intent is to apply for participation in a Health Plan network, please send only to the Plan(s) you are
interested in joining. NOT ALL Plans provide services in every county. Please contact the Plan directly to verify
that they provide services in your county and that they are accepting new providers.
If you are adding a practitioner under an existing Health Plan contract, please only send to the Plan(s) you
are contracted with.
HEALTH PLAN
PHONE
FAX/EMAIL
WEBSITE
Arizona Complete Health
- Complete Care Plan
(888)788-4408
(866)687-0514
AzCHProviderData@azcompletehealth.com
www.azcompletehealth.com
Banner University
Health Plans
(520) 874-5290
or
(800) 582-8686
Email is preferred method to send completed
PDFs:
BUHPDATATEAM@Bannerhealth.com
(520) 874-7142
www.BannerUFC.com/
ACC
www.BannerUFC.com/AL
TCS
www.BannerUCF.com
www.BannerUHP.com
Care1st Health Plan
Arizona
(602) 778-1800
(options in order 5, 7)
(602) 778-1875
SM_AZ_PNO@care1stAZ.com
www.care1staz.com
DentaQuest
(800) 233-1468
initialproviderenrollment@dentaquest.com
(262)241-7401
http://www.dentaquest.com/st
ate-
plans/regions/arizona/az-
dentist- page
Health Choice
Arizona
(800) 322-8670
(options in order 4, 7)
If not yet contracted: Email form to
HCHContracting@healthchoiceaz.com
If contracted: Email form to your Provider
Representative or
HCHCredentialing@healthchoiceaz.com
(480) 760-4975
www.healthchoiceaz .com
Molina Complete
Care of Arizona
(800) 424-5891
MCCAZ-Provider@molinahealthcare.com
www.mccofaz.com
Mercy Care
(602) 263-3000
Network Management (Provider Relations and
Contracting)
MercyCareNetworkManagement@MercyCareAz.org
Fax: (860)975-3201
www.mercycareaz.org
UnitedHealthcare
Community Plan
For questions please
email
networkhelp@uhc.com
Submission to the RFP Portal is the preferred
method for accepting the pdf UHC RFP Portal
(855) 523-9998
Cred_applications@uhc.com
www.uhcprovider.com
Each plan retains the right to make their own contracting decisions (whether or not to add practitioners to their network) and also will make their
own credentialing committee decisions (review of the primary source verification information obtained by Aperture Credentialing, LLC resulting in
approval/denial by the plan’s committee). You will receive separate communication from each plan regarding the effective date of your
credentialing and the effective date of your contract.
REVISED 2021 10
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
SUPPLEMENTAL FORM FOR ADDITIONAL ADDRESSES
PLEASE NOTE: A separate Provider Assessment of Cognitive and Physical Disabilities Accommodations must be completed for each location unless the
accommodations are the same as the Primary Address. If the accommodations are the same, indicate “ALL” on the form under Practice Location. If accommodations
do vary by location, a separate Assessment must be completed. Indicate appropriate address location on the form under Practice Location.
ADDITIONAL
LOCATION
(Physical location
where services
are performed)
Supplemental
sheet attached
for additional
addresses
Address:
City:
State:
Zip Code:
Phone:
Fax:
County:
Provider Office Hours (highlight all that apply)
S M T W TH F S
Time Open: Time Closed:
Special note (i.e. closed for lunch, etc)
List Practitioner in Directories at this address? YES NO
ADDITIONAL
LOCATION
(Physical location
where services
are performed)
Supplemental
sheet attached
for additional
addresses
Address:
City:
State:
Zip Code:
Phone:
Fax:
County:
Provider Office Hours (highlight all that apply)
S M T W TH F S
Time Open: Time Closed:
Special note (i.e. closed for lunch, etc)
List Practitioner in Directories at this address? YES NO
ADDITIONAL
LOCATION
(Physical location
where services
are performed)
Supplemental
sheet attached
for additional
addresses
Address:
City:
State:
Zip Code:
Phone:
Fax:
County:
Provider Office Hours (highlight all that apply)
S M T W TH F S
Time Open: Time Closed:
Special note (i.e. closed for lunch, etc)
List Practitioner in Directories at this address? YES NO
ADDITIONAL
LOCATION
(Physical location
where services
are performed)
Supplemental
sheet attached
for additional
addresses
Address:
City:
State:
Zip Code:
Phone:
Fax:
County:
Provider Office Hours (highlight all that apply)
S M T W TH F S
Time Open: Time Closed:
Special note (i.e. closed for lunch, etc)
List Practitioner in Directories at this address? YES NO
REVISED 2021 11
Credentialing Alliance
AZAHP PRACTITIONER DATA FORM
SUPPLEMENTAL FORM FOR ADDITIONAL PRACTITIONERS IN CALL GROUP AND HOSPITAL/AMBULATORY
SURGERY PRIVILEGES
PRACTITIONERS IN CALL GROUP (MUST BE CONTRACTED WITH PLAN)
HOSPITALS AND AMBULATORY SURGERY CENTER(S) WHERE PRACTICTIONER
HAS PRIVILEGES:
Practitioner Data Form completed by:
Name:
Title:
Date:
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Completed 11 March 2022

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