Fillable arizona health care cost provider registration form 12/2011

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arizona health care cost provider registration form 12/2011

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File type: PDF

U.S.A. forms for Arizona Health Care Cost Containment System

BROWSE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) FORMS

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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
1a) PROVIDER AHCCCS ID NUMBER (Complete Only if you are currently
registered and have a Provider No)
1b) PROVIDER NPI (NATIONAL PROVIDER IDENTIFIER) NUMBER (if
applicable)
2) PROVIDER NAME(Last Name/First Name/Middle Initial or business/facility name)
3) SOCIAL SECURITY NUMBER 4) DATE OF BIRTH 5) GENDER 6) DEGREE
7) PROVIDER TYPE 8) FFS TYPE 9) IHS INDICATOR
10) APPLICATION DATE
Month
Day Year
11) FIRST DATE OF SERVICE FOR WHICH A CLAIM WILL BE SUBMITTED
Month
Day Year
SECTION II ADDRESS INFORMATION
CORRESPONDENCE ADDRESS
ADDR SITE
C 01 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
PAY-TO ADDRESS
ADDR SITE
P 01 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
ADDITIONAL PAY-TO INFORMATION 21) END DATE:
22) EMPLOYER TAX ID:
SERVICE ADDRESS
ADDR SITE
S 01 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE:
16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
20) BEGIN DATE:
21) END DATE:
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION CODE:
Page 2
PAY-TO ADDRESS
ADDR SITE
P 02 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
ADDITIONAL PAY-TO INFORMATION 21) END DATE:
22) EMPLOYER TAX ID:
SERVICE ADDRESS
ADDR SITE
S 02 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
20) BEGIN DATE:
21) END DATE:
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION CODE:
PAY-TO ADDRESS
ADDR SITE
P 03 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE: 16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
ADDITIONAL PAY-TO INFORMATION 21) END DATE: 22) EMPLOYER TAX ID:
SERVICE ADDRESS
ADDR SITE
S 03 12) STREET LINE 1:
13) STREET LINE 2:
14) CITY/STATE/ZIP:
15) COUNTY CODE:
16) COUNTRY CODE:
17) BUSINESS PHONE: ( ) - 18) EMERGENCY PHONE ( ) -
19) ATTENTION TO:
20) BEGIN DATE:
21) END DATE:
ADDITIONAL SERVICE INFORMATION: 23) PAY-TO LOCATION CODE:
Page 3
SECTION III
LICENSING
*
24) LICENSE NUMBER 25) ISSUE DATE (MM/DD/YYYY) 26) EXPIRATION DATE 27) NEXT RENEWAL DATE
*
A COPY OF THE LICENSE MUST BE ATTACHED
PROVIDER SPECIALTY INFORMATION- MANDATORY FOR PHYSICIAN, DENTISTS, PODIATRISTS,
OSTEOPATHS, AND REGISTERED NURSE
PRACTITIONERS
28) SPECIALTY 29) BEGIN DATE (MM/DD/YYYY) 30) END DATE
BED COUNT INFORMATION - HOSPITALS, NURSING HOMES, AND HOSPICES ONLY
31) BED TYPE 32) STATE CERTIFIED
COUNT
33) MEDICARE
CERTIFIED COUNT
34) MEDICAID
CERTIFIED COUNT
35)
(MM/DD/YYYY)
BEGIN DATE 36) END DATE
SECTION IV
AUTHORIZED SIGNATURE
37) SIGNATURE 38) PRINT NAME 39) BEGIN DATE (MM/DD/YYYY)
Page 4
GROUP BILLING AUTHORIZATION
40) GROUP NAME/AHCCCS ID NUMBER AND/OR NPI NUMBER 41) I
(MM/DD/YYYY)
ASSOCIAT ON BEGIN DATE 42) ASSOCIATION END DATE
MEDICARE INFORMATION (Mandatory for all providers. If not a Medicare provider indicate by placing N/A in block #42)
43) MEDICARE
ID NO
44) MEDICARE
COVERAGE
45) INTERMEDIARY
NUMERIC CODE
46) CARRIER
NUMERIC CODE
47)
(MM/DD/YYYY)
BEGIN DATE 48) END DATE
Has the practice/organization that you represent or any of the signatories listed in (37) 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 in (37) 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 hereby authorize the groups listed in (40) to bill on my behalf and receive payment for services provided to AHCCCS members.
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.
49) 50)
PROVIDER SIGNATURE (ONLY) DATE
51)
PROVIDER NAME (PLEASE TYPE OR PRINT)
12/2011
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Completed 1 December 2019

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