STATE OF ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
PROMOTING HONESTY AND INTEGRITY
OFFICE OF INSPECTOR GENERAL
Douglas A. Ducey
Governor,
Governor
______________________________________________________________________
GROUP BILLING AUTHORIZATION
Complete one authorization form for each provider and group.
I understand that I must notify AHCCCS, Provider Registration of any changes to the group
billing arrangements 30 days in advance. Notification must include the effective date of change.
PLEASE TYPE OR PRINT IN INK.
1. I hereby authorize __________________________________________________
(Group Name)
__________________ to bill on my behalf for services provided to AHCCCS members
(Group ID Number/NPI Number)
for claims with dates of service on or after _________________________.
(Date of Group Affiliation)
____________________________ ________________________
(Signature) (Date)
____________________________ _________________________
(Printed Name) (Provider ID Number)
(NPI Number)
01/2015
