Fillable GrpBillerRegForm - New_GRPBILLER REG FORM 6-2010

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GrpBillerRegForm - New_GRPBILLER REG FORM 6-2010

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File type: PDF

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Page 1
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
PROVIDER REGISTRATION FORM
SHADED FIELDS FOR AHCCCS PROVIDER REGISTRATION STAFF ONLY Please Type or Print in Ink
SECTION I
1) PROVIDER ID NO (Complete Only if you are currently registered and have a
Group Provider No)
PROVIDER NPI (NATIONAL PROVIDER IDENTIFIER) NUMBER (if applicable)
2) PROVIDER NAME(Enter the company name)
7) FFS TYPE 8) IHS INDICATOR
9) APPLICATION DATE
Month
Day Year
10) FIRST DATE OF SERVICE FOR WHICH A CLAIM WILL BE SUBMITTED
Month
Day Year
SECTION II ADDRESS INFORMATION
CORRESPONDENCE ADDRESS (Enter the address to which all correspondence other than payments are to be mailed)
ADDR SITE
C 01 11) STREET LINE 1:
12) STREET LINE 2:
13) CITY/STATE/ZIP:
14) COUNTY CODE:
15) BUSINESS PHONE: ( ) - 16) EMERGENCY PHONE ( ) -
17) ATTENTION TO:
PAY-TO ADDRESS (Enter the address to which payments are to be mailed)
ADDR SITE
P 01 11) STREET LINE 1:
12) STREET LINE 2:
13) CITY/STATE/ZIP:
14) COUNTY CODE:
15) BUSINESS PHONE: ( ) - 16) EMERGENCY PHONE ( ) -
17) ATTENTION TO:
18) EMPLOYER TAX ID:
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Page 2
SECTION III Authorized Signature This section is optional. Completion of this section authorizes
representatives to act as a signor for the group with regard to AHCCCS claims and correspondence. The
authorized representative must sign below with their usual signature. Please note for the initial registration
process the CEO, CFO or Administrator of the organization must sign this registration form. The authorized
signor can sign the Provider Participation Agreement.
Signature:_____________________________ Print Name:_____________________________ Begin Date:_________________
Signature:_____________________________ Print Name:_____________________________ Begin Date:_________________
Signature:_____________________________ Print Name:_____________________________ Begin Date:_________________
Completion of the following questions is mandatory
Has the practice/organization that you represent or any of the signatories listed above ever applied for or received an AHCCCS provider
identification number under any other name than noted on this form?
NO
YES (Please explain)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Have you or the practice/organization that you represent or any of the signatories listed above ever been terminated, suspended, advised of
any deficiencies or otherwise subject to any corrective or disciplinary action by a governmental body? This includes a professional licensing
or certification board and any city, state, county or federal entities. If yes, include documentation from issuing entity.
NO
YES (Please explain)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
I affirm under penalty of law that the information I have provided on this form is true, accurate and complete to the best of my knowledge.
48) 49)
PROVIDER SIGNATURE (ONLY) DATE
50)
PROVIDER NAME (PLEASE TYPE OR PRINT)
Rev: 6-2010
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GrpBillerRegForm - New_GRPBILLER REG FORM 6-2010

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Completed 20 November 2019

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