AWMB Provider Credentialing Application

1

Provider Information

Last Name *

First Name *

M.I.

Credential / Title

Other Names Used (maiden, former)

Date of Birth *

Place of Birth

Citizenship

Specialty *

Practice / Group Name

Foreign Language(s) Spoken

Telehealth Services?

Yes No

Register as Primary Care (PCP)?

Yes No

Target / Start Date

When do you need to be able to bill?

Identity & Enrollment Profile

Gender Identity

1099 Registered Name

Must match IRS records — required for AzAHP

Effective Date with Practice

Medicare Enrollment Type (CMS-855I)

Practitioner Type — check all that apply

PCP OB/GYN Specialist BH Dentist MAT Prescriber

Lines of Business

Medicaid Medicare Commercial

Group Type — check all that apply

FQHC/RHC Integrated Clinic Multi Specialty Single Specialty Group Other

Business Structure (Medicare 855I/855B)

Participates in Medicare?

Yes No

Hospital Based Only?

Yes No

Applying as Group Practice or Facility?

Yes — Group / Facility No — Individual only

If yes, a Group/Facility section (AzAHP Org + CMS-855B) will appear below

A

AzAHP Clinical Profile

AHCCCS Managed Care Plans

📄 Required for AzAHP (AHCCCS managed care plans): Arizona Complete Health, Banner UHP, BCBSAZ Health Choice, Molina, Mercy Care, UHC Community Plan.

Patient Acceptance

Accepting New Patients?

Yes No

Accepting New Medicare Patients? (855I)

Yes No

Patient Age Range

Patient Gender Accepted

PCP Panel Restrictions

Secondary Specialty & MAT

Secondary Practicing Specialty

Secondary Board Certification?

Yes No Board Eligible

→ MAT Prescriber — XDEA Information

XDEA Number

State

Expiration Date

Clinical Capabilities

PCPs and OBs only — services provided

EPSDT OB None / Not Applicable

Specialized Training / Certifications

Health Equity Diversity Equity Inclusion Trauma Informed Care

Trained in AAP Developmental Screening Tools?

Yes No

E-Prescribe?

Yes No

Accommodations — difficulty communicating / cooperating (autism, intellectual disabilities)?

Yes No

Accommodations — mobility limitations / wheelchair bound?

Yes No

Physician Assistant Information

PA Supervising Physician Name

Collaborative PA Practice?

Yes No

VFC, Field & Virtual Clinic

Participate in VFC (Vaccines for Children)?

Yes No

PCPs seeing AHCCCS members 18 & under must participate

VFC PIN Code

Provide Field Clinic Services?

Yes No

Provide Virtual Clinic Services?

Yes No

Render services in patients' homes? (CMS-855I)

Yes No

Service areas (if rendering in homes)

Hospital Privileges & Call Group

Hospital & Ambulatory Surgery Centers where provider has privileges

Names of Practitioners in Call Group (must be contracted with plan)

Demographics (Optional — AzAHP)

2

Provider Identifiers

Social Security Number *

Required for payer enrollment applications

Tax ID # (EIN or SSN used for billing)

EIN SSN

NPI Type 1 (Individual) *

NPI Type 2 (Group / Organization)

AHCCCS #

Group Medicare #

Individual PTAN

Group PTAN

AHCCCS Billing Provider ID

AHCCCS Rendering / Servicing Provider ID

Certification & License Details (CMS-855I)

Active Certification Number

Certifying Entity

Certification Effective Date

Certification State

Compact License?

Yes No N/A

Non-Physician Specialty Type (CMS-855I — if applicable)

MAT XDEA # (if MAT Prescriber)

See AzAHP Clinical Profile section above for full XDEA details

CAQH ID #

CAQH Username

CAQH Password

3

Addresses & Contact

Primary Office / Practice

Street Address *

Office Phone *

Office Fax

Billing Address

Street Address

Leave blank if same as primary office

Billing Phone

Billing Fax

Home Address

Street Address *

Home Phone

Email Address *

Office Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Special Considerations (lunch closures, etc.)

Languages spoken by Office Staff

List in Provider Directories?

Yes No

Pay To Address (all payments sent here)

Pay To Street Address

Leave blank if same as primary office. This maps to CMS-855I Section 4C / AzAHP Pay To Address.

City

State

ZIP Code

Correspondence Mailing Address (CMS-855I — if different from practice location)

Correspondence Address

Office Contact & Practice Operations

Office Contact Name / Title

Office Contact Email

Practice Website

Medical Record System (EMR)

Billing / A/R System

Medical Records Storage Location (if not at practice)

Electronic Claims Submission?

Yes No

Electronic Funds Transfer (EFT)?

Yes No

Internet Access?

Yes No

Minority or Female Owned Business?

Yes No

4

Licensure & DEA

Attach copy of AZ license

State Licenses — List all licenses ever held

DEA Registration

DEA Number

Date Issued

Expiration Date

AZ License (quick reference)

AZ License Number

Expiration Date

5

Education & Training

Attach copies of all certificates

📄 Please attach copies of all certificates: M.D., Internship, Residency, Fellowship, MSN (for NPs).

Quick Reference

Medical School

Residency

6

Board Certifications

Attach copies of certificates

7

Work Experience — Past 5 Years

8

Malpractice Insurance

Attach current certificate

📄 Please email a copy of your current malpractice insurance certificate to your AWMB contact after submitting this form.

Insurance Carrier Name

Policy Number

Effective Date

Expiration Date

Per Occurrence Limit

Aggregate Limit

9

Payers to Enroll With

Select all payers you would like AWMB to enroll you with. You may request additional payers at any time.

10

Medicare Enrollment Questions

Required if enrolling in Medicare

Do you own this business?

Yes No

→ Since you own the business, please answer the following:

Are you the only owner, or is there more than one owner?

I am the sole owner There is more than one owner

What IRS form do you use to file the business' taxes?

Form 1040 — taxed as individual / sole proprietor / disregarded entity Form 1120 — elected to be taxed as corporation or S-Corp Form 1065 — partnership

If filing on Form 1120, be prepared to provide supporting documentation (Form 8832, 2553, or IRS letter confirming S-Corp status).

Will there be other employees reassigning benefits to the organization, or will you be the only one?

Yes — there will be other employees besides myself reassigning benefits No — I will be the only person reassigning benefits

What are the hours of operation for the business?

L

Final Adverse Legal Actions (Medicare 855I / 855B)

Required for Medicare enrollment

⚠ Report ALL final adverse legal actions regardless of whether records were expunged or appeals are pending. If YES to any item, provide a complete description in the Notes field that appears.

Federal & State Convictions (within preceding 10 years)

Question	Yes	No

Exclusions, Revocations & Suspensions

Question	Yes	No

11

Health Status

⚠ If the answer to any question is YES, you will be asked to provide a written explanation. You may add notes in the box that appears.

Present health status

Good Fair Poor

Question	Yes	No

12

Licensure History

⚠ If the answer to any question is YES, provide a written statement. Notes fields appear automatically.

Question	Yes	No

13

Insurance & Legal Action

⚠ If the answer to any question is YES, provide a written statement. Notes fields appear automatically.

Question	Yes	No

D

Disability Accommodations Assessment

AzAHP — required for each practice location

📄 AzAHP requires this assessment for each practice location. If accommodations are the same at all locations, enter "ALL" in the location field.

Practice Location Address this assessment applies to

Accommodation	Yes	No	N/A

G

Group Practice / Facility Application

AzAHP Org/Facility Form + CMS-855B

📄 Complete this section for the organization or facility. The individual practitioner information above is separate. This covers the AzAHP Organization/Facility Application and CMS-855B (Clinics/Group Practices).

Organization / Facility Identification

Org/Facility Legal Name (1099 Registered)

Tax ID # (EIN)

Organization / Facility Name (DBA if applicable)

Effective Date with TIN

Organization NPI (Type 2)

Medicare PTAN (Group)

AHCCCS ID #

AHCCCS Provider Type

CLIA # (if applicable)

CLIA Expiration Date

Medicare Participating Provider?

Yes No

IRS Business Designation (CMS-855B)

Business Structure (CMS-855B)

Lines of Business

Medicaid Medicare Commercial

IHS Facility (Indian Health Services)?

Yes No

Type of Supplier (CMS-855B)

Facility Type (AzAHP — check all that apply)

Acute Rehab Ambulatory Surgery Center Attendant Care Agency Assisted Living Center Assisted Living Home Behavioral Health Behavioral Health Residential (BHRF) Dialysis DME / Enteral FQHC / RHC Habilitation Providers Home Health Agency Hospice Hospital Infusion Agency Intensive Outpatient Treatment (BH) Laboratory Pharmacy PT / ST Radiology Skilled Nursing Facility (SNF) Transportation Urgent Care Other

Accrediting Authorities (check all that apply)

Accreditation Commission for Health Care (ACHC) AAAHC (Ambulatory Surgery) AAAHC (Ambulatory Health Care) American College of Radiology American Osteopathic Association CARF (Rehabilitation Facilities) Commission on Office Laboratory Accreditation Community Health Accreditation Det Norske Veritas (DNV NIAHO) Healthcare Facilities Accreditation Program Joint Commission (TJC)

Primary Facility Address & Contact

Facility Street Address *

City

State

ZIP Code

Appointment Phone

Fax

County

Org/Facility Email

Org/Facility Website

Contact Name / Title

List in Provider Directories?

Yes No

Ownership Interest (CMS-855B Section 6) — individuals with 5%+ ownership

Authorized / Delegated Official (CMS-855B)

Authorized Official First Name

Authorized Official Last Name

Title

Date of Birth

SSN

Phone

Email

Facility Practice Operations

Medical Record System (EMR)

Billing / A/R System

Electronic Claims Submission?

Yes No

EVV (Sandata) Training Completed?

Yes No N/A

Minority or Female Owned Business?

Yes No

AzAHP Org/Facility Disclosure Questions

⚠ If the answer to any question is YES, provide a complete description in the notes field.

Question	Yes	No

14

Additional Notes

Anything else we should know

📎

Documents

Upload your credentialing documents here

🔒 Files are stored securely in your AWMB credentialing portal. Accepted formats: PDF, JPG, PNG. Max 10 MB per file.