Office Location Credentialing Form
ENTITY INFORMATION
Please upload your entity's W-9
*
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Practice Name
*
Legal Business name on W-9
*
TAX ID Number
*
Group NPI Number
*
Office manager email address
*
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office phone number
*
Office Fax number
*
Languages spoken in your office (please list)
*
Practice Owner Information
Owner Name
*
Owner's Date of Birth
*
-
Month
-
Day
Year
Date
Owner's NPI
*
Owner's SSN
*
Owner's Signature
*
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% of Ownership in the Entity
*
Primary Office Location
Primary Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
*
Office Fax
*
Office Hours
*
Languages Spoken by office staff
*
LIST OF INSURANCES THAT YOU WOULD LIKE THIS OFFICE TO BE CREDENTIALED WITH
PPO
*
Please list the names of PPO Insurance Plans that you would like this office location to be credentialed with if it's missing from the list above
AHCCCS
*
Please list the names of AHCCCS Insurance Plans that you would like this office location to be credentialed with if it's missing from the list above
Credit Card Information
Card Type
*
Please Select
VISA
MASTER CARD
AMERICAN EXPRESS
DISCOVER
OTHER
Cardholder Name (as shown on card):
*
Card Number
*
Number digit only
Expiration Date
*
mm/yyyy
CVV:
*
CVV4:
*
Billing zip code
*
Financial Institution Information
Financial Institution Name
Financial institution routing number
Provider’s account number with financial institution
Type of account at financial institution
Please Select
Checking
Savings
Account Number Linkage to Provider Identifier
Please Select
Provider Tax Identification Number (TIN)
National Provider Identifier (NPI)
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Please send a copy of a voided check or a letter from your bank with your paper enrollment form .
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