AzAHP Credentialing Form Updates

Date: 10/28/24

 

AzAHP Credentialing Alliance

 CREDENTIALING FORM UPDATES

Dear Providers and Credentialing Staff:                                                                                                                 

Based on the recommendations and approval from the Arizona Association of Health Plans (AzAHP) Credentialing Alliance, the following forms have been updated:

Practitioner Data Form

o   Gender fields updated

o   Languages spoken by practitioner updated to clarify “fluent” languages

o   Race and Ethnicity fields updated

o   Signature Page now includes reminder that forms must be signed within 180 days of submission to the Plan

Organizational/Facility Application

o   Instructions updated

o   Effective Date with TIN field added

o   Assisted Living Facility/SNF Type Specialties added

o   Languages spoken by practitioner updated to clarify “fluent” languages

o   Signature Page now includes reminder that forms must be signed within 180 days of submission to the Plan

Please begin using the updated forms no later than November 15, 2024.

Visit our website to access the updated forms: https://www.azcompletehealth.com/providers/become-a-provider/credentialing-forms.html

Forms, instructions along with additional educational resources are also available on the AzAHP Credentialing Alliance website at: https://azahp.org/azahp/welcome-to-the-credentialing-alliance.

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.

Thank you!