Get Azahp Organizational Data Form - Health Net

Filling out the AzAHP Organizational Data Form is an essential step for new providers seeking to join the Health Net network. This guide provides clear and supportive instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out your tax ID number and 1099 registered name. Ensure that the facility name or 'doing business as' (DBA) is provided if applicable.
3. Indicate the lines of business by checking the relevant boxes for Medicaid, Medicare, and commercial services. Specify if the provider is a Medicare participating provider.
4. Provide the state and license number, along with the AHCCCS ID number and its expiration date. Fill in the organizational NPI number.
5. Select all applicable facility types from the list provided, which includes options like acute rehab, urgent care, and home health.
6. Enter the primary address for the location where services will be performed. Attach any additional locations accordingly.
7. Complete the billing address section, ensuring all contact details such as phone numbers and emails are accurate.
8. Provide details about your medical and cost record-keeping systems and indicate whether electronic claims submission and electronic funds transfer are available.
9. Answer questions regarding internet access and whether the business is minority or female-owned, as specified.
10. Once all information is entered, review the form for accuracy. Save changes and use available options to download, print, or share the form as needed.

Complete your AzAHP Organizational Data Form online today to streamline your credentialing process.