Fillable PROVIDER TYPE PROFILE physician

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PROVIDER TYPE PROFILE physician

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PROVIDER TYPE PROFILE
PROVIDER
TYPE
18 PHYSICIANS ASSISTANT
REIMBURSE-
MENT TYPE
02 FEE FOR SERVICE
EFFECTIVE 07-01-88
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY 01 MEDICINE JOINT BOARD ON REGULATION
PHYSICIAN ASSISTANTS
MANDATORY 02 SURGERY JOINT BOARD ON REGULATION
PHYSICIAN ASSISTANTS
MANDATORY
OPTIONAL 03 RESPIRATORY THERAPY
OPTIONAL 05 OCCUPATIONAL THERAPY
OPTIONAL 06 PHYSICAL THERAPY
OPTIONAL 07 SPEECH/HEARING THERAPY
OPTIONAL 08 EPSDT
OPTIONAL 09 PHARMACY DRUG ENFORCEMENT AGENCY
OPTIONAL 12 PATHOLOGY AND LAB CLIA LICENSE/WAIVER
OPTIONAL 13 RADIOLOGY
OPTIONAL 15 DME AND APPLIANCE
OPTIONAL 27 IHS OUTPATIENT SERVICES (ASSIGNED TO IHS PROVIDERS)
OPTIONAL 40 MEDICAL SUPPLIES
OPTIONAL 45 REHABILITATION
OPTIONAL 47* MENTAL HEALTH MUST BE SUPERVISED BY AN AHCCCS
REGISTERED PSYCHIATRIST
* SPECIAL INSTRUCTIONS: I am the supervising psychiatrist,
(Psychiatrist Name)
AHCCCS provider ID # .
_____________________________________________ ____________________
(Psychiatrist’s Signature) (Date)
_____________________________________________ ___________________
(Physician Assistant’s Signature) (Date)
This provider also may be assigned COS 47 as a behavioral health medical practitioner if the provider
submits a letter attesting to one year of full time behavioral health work experience.
REVISED11/15/2012
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PROVIDER TYPE PROFILE physician

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Completed 16 December 2019

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