Provider Data Reporting

Are you a provider looking to report inaccurate data on our Find a Provider or are you looking to validate your information? If yes, this form is for you.

Below you will be given the option of listing your information and helping us ensure we show our members the most up-to-date and valid data.

If you have any questions or would like to submit or validate your information by phone or email, use the following information:

Phone: 1-888-788-4408
Fax: 1-866-687-0514
Email: AzCHProviderData@azcompletehealth.com

Name of Person Filling Out the Form *

Position Title of Person Filling Out Form *

Provider Name *

Group NPI or Tax ID *

Practitioner NPI *

Provider Phone Number *

Provider Email Address *

Provider Address *

Ex. 1234 Test Street Phoenix, AZ 12345

What information will need to be updated? *

Please attach any supporting documentation for your request – Thank you!

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