Potential Provider Application

Provider Speciality *

Facility Site Name *

Address

Address Line 1 *

Address Line 2

City *

State *

ZIP *

Facility Information

Hours Of Operation *

Phone *

Fax *

Email *

Website

Dept. of Licensure License

AHCCCS Registered *

Yes No

AHCCCS Provider Type (2 Characters) *

For those organizations without an AHCCCS ID, click here to identify your Provider Type.

Populations Served

Counties Served *

Specific Populations Serving *

Specific Age Groups *

Male / Female *

Services

Description *

Please include a short description of specific treatment services and programs offered and include in your packet any marketing materials to present to the committee. Be sure to highlight how your agency/programs are different or unique from other agencies in your provider type.

Contact Information

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone *

Additional Information

Do you Have an Electronic Medical Record *

Yes No

What Speciality Certifications do you hold *

Are you a Medicare Provider *

Yes No

Do your staff bill under the same Tax ID number (TIN)? *

Yes No

TIN Number *

Do you have experience working with other T/RBHAs? *

Please List Other T/RBHAs Names:

Attestation *

By checking this box, I attest that I am able to procure and maintain the required insurance and will furnish Cenpatico with certificates of insurance during the credentialing process, provided that subcontractor is approved by the Committee for a contract.

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