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Potential Provider Application

Required fields are marked with an asterisk (*)

Which product line(s) are you interested in? required *
Electronic Visit Verification Provider? required *

Contracting Representative

Provider Information

Provider Identification Numbers

Medicare Provider?
Are you AHCCCS Registered?
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Specialty & Services Provided

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Populations Served

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To select multiple items in a list, hold down the Ctrl (PC) or Command (Mac) key, then click on your desired items.
To select multiple items in a list, hold down the Ctrl (PC) or Command (Mac) key, then click on your desired items.

Additional Information

Do you Have an Electronic Medical Record? required *
Is there a remote connection option?
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Do your staff bill under the same Tax ID number (TIN)? required *
Attestation required *