Follow the steps to effectively complete the Azahp Organizational Credentialing Form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing organizational data. Input your tax ID number, 1099 registered name, and license numbers. Be sure to include your organizational NPI number and facility type(s). Select all applicable types from the checklist provided.
3. Complete the primary address section. Enter the physical location where services are performed, including the address, city, state, and zip code.
4. Provide your contact information, including phone number, fax number, and email address for the credentialing contact.
5. Attach necessary documents as specified, such as IRS 941 coupon or W9, liability insurance certificates, accreditation certificates, and Medicaid-required insurance certificates.
6. Answer specific questions about your medical record keeping system, cost record keeping system, and electronic claim submission capabilities.
7. Indicate whether your organization meets the insurance requirements if requesting to participate in Medicaid. Provide details about your commercial general liability, worker's compensation, and professional liability coverage.
8. Review the entire form for completeness and accuracy. Once all sections are finished, save your changes.
9. Download, print, or share the form as needed to complete your submission.

Complete the Azahp Organizational Credentialing Form online to ensure a smooth credentialing process for your organization.