Revised 1/2020 (CYE2020) Page 1 of 11 SEE PAGE 11 FOR FAX AND PHONE INFORMATION
PRACTITIONER DATA FORM
Directions for completion of the Practitioner Data Form (PDF)
1. Ensure your CAQH application and attestation is up to date and that each health plan you are requesting participation in is authorized to access
2. PLEASE TYPE OR PRINT CLEARLY & COMPLETE PAGES 2-6 IN ITS ENTIRETY
a. Please use a separate sheet if necessary, to include all hospital and ambulatory surgery centers where you have privileges
b. Please use a separate sheet if necessary, to include all Practitioners in Call Group—must be contracted with the plan
c. Additional Offices—Page 3 has space for one additional location. Please indicate any additional locations/offices on a separate sheet
3. Please complete the Provider Assessment of Cognitive and Physical Disabilities Accommodations assessment (Pages 4-5). A separate assessment
must be completed for each location.
4. The following ATTACHMENTS are required to be submitted with the PDF SO YOUR REQUEST MAY BE PROCESSED TIMELY
a. Copy of your Board Certification (if applicable) or CMEs in your specialty
b. Copy of W-9
c. Copy of your Certificates of Insurance information that include the minimum requirements (Commercial General Liability, Business
Automobile Liability, Workers’ Compensation Liability and Professional Liability--see pages 6-7)
d. The following endorsements, waiver of subrogation and/or SAM language as applicable must be submitted with the certificates. Use of the
Insurance Checklist to make sure all coverage levels, endorsement and waivers have been addressed.
i. Endorsement—Required for Commercial General and Business Auto Liability
a. 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 actives
performed by the Subcontractor or on behalf of the Subcontractor or Contractor
ii. Waiver of Subrogation—Required for all
a. 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.
iii. **Sexual Abuse and Molestation (SAM)--Required for Commercial General Liability or Professional Liability when providing services to
children and/or vulnerable adults
nsurance Certificate(s) must provide the follow
ing statement “Sexual Abuse and
Molestation coverage is included” or “Sexual
Abuse and Molestation coverage is not excluded”.
b. 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.
**Please check with health plan if SAM coverage is required for your specific provider type
iv. NOTE: Please see the Certificate of Liability Insurance samples at the end of this document (pages 9-10)
a practicing OB/GYN and you are performing Detailed Anatomic Fetal Ultrasound, provide documentation of 30 hours of CME i
anatomic ultrasound (30 hours of CMEs every 3 years)
5. New providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives
written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee and signed
contract, if applicable).