Get Az Ahp Practitioner Data Form 2021-2025

The AZ AHP Practitioner Data Form is essential for practitioners seeking participation in Arizona Health Plans. This guide outlines a step-by-step process to assist users in completing the form accurately and efficiently online.

Follow the steps to fill out the AZ AHP Practitioner Data Form online effectively.

1. Click the ‘Get Form’ button to access the AZ AHP Practitioner Data Form and open it in the online editor.
2. Begin by entering your practitioner information, including your full name and degree. Ensure the details are accurate and typed clearly.
3. Provide your CAQH number, ensuring it is correct, as inaccuracies may lead to delays in processing.
4. Indicate your date of birth and 1099 registered name, followed by your tax ID number.
5. Fill in your group practice name (if applicable), effective date with practice, and check the relevant group type affiliations.
6. Complete the sections regarding your primary and secondary practicing specialties, board certifications, and acceptance of new patients.
7. If applicable, provide your AHCCCS ID and details about any specializations or services offered.
8. Complete the Provider Assessment of Cognitive and Physical Disabilities Accommodations tool, ensuring you note any accommodations provided for individuals with disabilities.
9. Attach the required documents as outlined in the instructions, including IRS 941 vouchers or W-9 forms, board certification documents, and insurance certificates.
10. Review all information for accuracy. Once confirmed, save your changes. You can download, print, or share the completed form as necessary.

Complete your AZ AHP Practitioner Data Form online today for timely processing!