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Get Ahccs Provider Address Update Form 2020-2025
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How to fill out the Ahccs Provider Address Update Form online
The AHCCCS Provider Address Update Form is essential for maintaining accurate provider information within the Arizona Health Care Cost Containment System. This guide is designed to assist you in completing this form online, ensuring a smooth and efficient process.
Follow the steps to accurately complete your form.
- Click the ‘Get Form’ button to access the form and open it in the designated editor.
- Begin by filling in the 'Name' field with your last name, first name, and middle initial. Ensure that the information is accurate as it will be used for identification purposes.
- Provide your Social Security number. This is essential for verifying your identity and status within the AHCCCS system.
- Indicate your gender by selecting either 'Female' or 'Male'. This helps in maintaining accurate demographic records.
- Enter your AHCCCS provider ID number and your National Provider Identifier (NPI) number. This allows for efficient updates to your provider record.
- Choose whether you are adding additional information or replacing existing information by checking the appropriate box.
- Fill in your correspondence address. Include all relevant details such as street address, city, state, zip code, and business phone number.
- Next, provide your emergency phone number and any attention to details if necessary.
- Repeat the previous steps for the pay-to address and service addresses, ensuring that you fill out all fields accurately for each site.
- At the end of the form, affirm the information's accuracy by signing, including your title and the date. This signature must be by the provider or authorized signatory on file with AHCCCS.
- Review all your entries for completeness and accuracy. You can then save changes, download, print, or share the form as required.
Complete your AHCCCS Provider Address Update Form online today to ensure your information is current and accurate.
You can reach the Connected Care provider services in Arizona by calling their dedicated member services line. They can provide assistance and answer questions about your healthcare needs. Don’t hesitate to ask about the AHCCCS Provider Address Update Form when you call, as they might help with that process too.
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