SUBMISSION INSTRUCTIONS The following items must be submitted with the completed form: Provider Group W9 The billing/payment address is taken directly from this document. Please ensure that it’s – accurate and up-to-date. Automobile Liability Certificate of Insurance (COI) Coverage must include a minimum combined single limit of $1 – million. Vehicle Maintenance Schedule this can include a checklist or policy that describes services performed on – vehicles to ensure the vehicle is operating properly. Checked child seat attestation This can be found in the Non-emergency Transportation Services section of this – form (page 2). If your organization or subcontracted transportation vendor provides transportation services to children, the box We are providing non-emergency transportation for AHCCCS members. We attest that we “Yes. are using age appropriate care seats when transporting children” must be checked. If your organization does not transport children, your organization’s policy stating such must be submitted. Submit all documentation to and . PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY Incomplete forms will be returned unprocessed. Any missing or expired documentation can PROCESS YOUR REQUEST. lead to processing delays or credentialing discontinuation. This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner. New providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee if applicable).
SUBMISSION INSTRUCTIONS PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. Incomplete forms will be returned unprocessed. Any missing or expired documentation can lead to processing delays or credentialing discontinuation. This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner. New providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee if applicable). The following items must be submitted with the completed form: Provider Group W9 – The billing/payment address is taken directly from this document. Please ensure that it’s accurate and up-to-date. Automobile Liability Certificate of Insurance (COI) – Coverage must include a minimum combined single limit of $1 million. Vehicle Maintenance Schedule – this can include a checklist or policy that describes services performed on vehicles to ensure the vehicle is operating properly. Checked child seat attestation – This can be found in the Non-emergency Transportation Services section of this form (page 2). If your organization or subcontracted transportation vendor provides transportation services to children, the box “Yes. We are providing non-emergency transportation for AHCCCS members. We attest that we are using age appropriate care seats when transporting children” must be checked. If your organization does not transport children, your organization’s policy stating such must be submitted. Submit all documentation to and .
Transportation%20Demographic%20Form.docx