Get Re-enrollment Address Verification Form - Ahcccs - Azahcccs

Filling out the Re-Enrollment Address Verification Form is essential for maintaining accurate records with the Arizona Health Care Cost Containment System. This guide will walk you through each section of the form to ensure clarity and efficiency in completing your online submission.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the Re-Enrollment Address Verification Form and open it for editing.
2. In the first section, enter your name as it appears on your legal identification. This should be in the format of Last, First, M.I. or Company Name.
3. Provide your social security number in the designated field. Ensure accuracy to prevent any delays.
4. Indicate your gender by selecting either Female or Male.
5. Fill in your AHCCCS provider ID number. If you do not have one, please refer to your provider documentation.
6. Enter your date of birth in the specified format.
7. Begin filling out the current addresses section by listing all relevant addresses. Pay particular attention to the correspondence address, ensuring to fill out each part including street, city, state, and zip code.
8. Provide your business phone number and, if applicable, your emergency phone number in the sections provided.
9. Repeat the address sections for each pay-to address and service address, keeping in mind that each service address must be a street address.
10. In the final section, affirm the accuracy and truthfulness of the information by signing the form. Include your title and the date.
11. Once all sections are completed, save your changes, and choose to download, print or share the form as needed.

Complete your Re-Enrollment Address Verification Form online today for a streamlined process.