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Single-Case-Agreement-Initial-Request-Form-07-20-16 Accessible PDF 2026
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- Click ‘Get Form’ to open the Single-Case-Agreement-Initial-Request-Form in our platform's editor.
- Begin by filling out the 'Member Information' section. Enter today's date, last name, first name, middle initial, date of birth, and AHCCCS ID. Indicate if the member is a Medicare member.
- Proceed to the 'Clinical Team Information' section. Input the provider organization name, address, TIN, NPI, and contact details for the clinical team lead.
- In the 'Rendering Provider/Facility Information' section, provide details about the rendering provider including their name, DBA (Doing Business As), service address, and billing address.
- Complete any internal use fields as necessary and ensure all required information is accurate before submitting your request.
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