AzAHP Credentialing Form Updates

Date: 10/06/23

Dear Providers and Credentialing Staff:

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

• Practitioner Data Form
• Facility Credentialing and Recredentialing Application
• Practitioner Practice Change Form

Changes include:

• Updated instructions on Page 1 for all three forms listed above
• Added field for how visits are provided: telemedicine, in-person, or both on the Practitioner Data Form
• Added field for panel restrictions on the Practitioner Data Form
• Corrected DEA field so it can be edited on the Practitioner Data Form
• Updates to formatting and field placement

Please begin using the updated forms for submissions on and after November 1, 2023.

Visit our websites to access the updated forms:

• Arizona Complete Health-Complete Care Plan
• Care1st

The forms, instructions on how to complete forms and other educational resources also are available on the AzAHP Credentialing Alliance website: https://azahp.org/azahp/welcome-to-the-credentialing-alliance.

AzCH providers and staff:

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.

Care1st providers and staff:

If you have questions, please call Network Management at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.

Thank you!