AZ AHCCCS Provider Address Update Form 2012 free printable template
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Janice K. Brewer Governor STATE OF ARIZONA ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM Thomas J. Betlach Director PROMOTING HONESTY AND INTEGRITY OFFICE OF INSPECTOR GENERAL Provider Address Update Form Completed W-9 Must Be Included NAME Last First M. I. SOCIAL SECURITY NUMBER GENDER FEMALE AHCCCS PROVIDER ID MALE DATE OF BIRTH NPI CHECK ONE ADD ADDITIONAL INFORMATION REPLACE EXISTING INFORMATION NOTE Form will be returned if not completed. CORRESPONDENCE ADDRESS STREET LINE 1 CITY...
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How to fill out ahcccs provider address change form
How to fill out AZ AHCCCS Provider Address Update Form
01
Obtain the AZ AHCCCS Provider Address Update Form from the official AHCCCS website or your provider portal.
02
Fill in the provider's name and National Provider Identifier (NPI) number accurately.
03
Provide the current address that is on file with AHCCCS.
04
Enter the new address details, ensuring all information is complete and correct.
05
Include contact information such as phone number and email address.
06
Sign and date the form to confirm the accuracy of the information provided.
07
Submit the completed form as instructed, either by mail or electronically, based on AHCCCS guidelines.
Who needs AZ AHCCCS Provider Address Update Form?
01
Healthcare providers who have changed their practice location or address.
02
Providers seeking to update their contact information for AHCCCS communications.
03
Any enrolled providers who need to inform AHCCCS of an address change to ensure compliance and avoid disruptions in service.
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People Also Ask about
How do I contact AHCCCS provider enrollment?
Contact Us For Online Provider Enrollment/Application Payment Questions: Call: Maricopa County: 602-417-4254. Statewide: 1-888-827-4420.
How do I contact AZ access?
Phone: In Maricopa County: 602-417-7100. Outside Maricopa County: 1-800-962-6690.
How do I check my AHCCCS status?
Phone Verifications: Maricopa County: 602-417-7200. Outside of Maricopa County, within Arizona: 1-800-331-5090.
Is AHCCCS the same as access?
Founded in 1982, the Arizona Health Care Cost Containment System (written as AHCCCS and pronounced 'access') is Arizona's Medicaid program, a federal health care program jointly funded by the federal and state governments for individuals and families who qualify based on income level.
How do I cancel my Arizona access?
AHCCCS members who want to stop receiving AHCCCS Medical Assistance during the declared COVID-19 emergency can stop benefits by: Logging into their Health-e-Arizona Plus account and asking for benefits to be stopped; or. Calling toll-free: 1-855-HEAplus (1-855-432-7587)
Who qualifies for AHCCCS in Arizona?
If your family's income is at or below 138% of the Federal Poverty Level (FPL) ($20,120 per year for an individual in 2023, $41,400 for a family of four), you may qualify for AHCCCS.
How do I speak to someone at AHCCCS?
Contact. Phone: In Maricopa County: 602-417-7100. Outside Maricopa County: 1-800-962-6690.
Can I cancel AHCCCS online?
AHCCCS members who want to stop receiving AHCCCS Medical Assistance during the declared COVID-19 emergency can stop benefits by: Logging into their Health-e-Arizona Plus account and asking for benefits to be stopped; or. Calling toll-free: 1-855-HEAplus (1-855-432-7587)
What is the income limit for access in AZ?
They must have limited income, limited assets, and a medical need for care. A single individual applying for Nursing Home Medicaid in 2023 in AZ must meet the following criteria: 1) Have income under $2,742 / month 2) Have assets under $2,000 3) Require the level of care provided in a nursing home facility.
What is Arizona's Medicaid called?
The Arizona Health Care Cost Containment System (AHCCCS) is Arizona's Medicaid agency that offers health care programs to serve Arizona residents. AHCCCS provides medical insurance coverage to thousands of Arizonans each year, for which DES provides eligibility services.
Is Arizona complete health the same as AHCCCS?
Arizona Complete Health has a proud history of serving Arizonans statewide through Medicare Advantage, Marketplace and AHCCCS. At Arizona Complete Health, our purpose is at the center of everything we do: Transforming the Health of the Community, One Person at a Time.
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What is AZ AHCCCS Provider Address Update Form?
The AZ AHCCCS Provider Address Update Form is a document used by healthcare providers in Arizona to update their address information within the Arizona Health Care Cost Containment System (AHCCCS) database.
Who is required to file AZ AHCCCS Provider Address Update Form?
All AHCCCS registered providers who change their business address or location are required to file the AZ AHCCCS Provider Address Update Form to ensure accurate records and communications.
How to fill out AZ AHCCCS Provider Address Update Form?
To fill out the AZ AHCCCS Provider Address Update Form, providers must provide their current and new address information, contact details, and any relevant provider identifiers. The form should be completed carefully to ensure accuracy.
What is the purpose of AZ AHCCCS Provider Address Update Form?
The purpose of the AZ AHCCCS Provider Address Update Form is to maintain up-to-date address records for providers within the AHCCCS system, facilitating communication and accurate service delivery to members.
What information must be reported on AZ AHCCCS Provider Address Update Form?
The information that must be reported on the AZ AHCCCS Provider Address Update Form includes the provider's current address, the new address, contact information, and any other required details specific to the provider's AHCCCS enrollment.
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