Single-Case-Agreement-Initial-Request-Form-07-20-16 Accessible PDF 2026

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  1. Click ‘Get Form’ to open the Single-Case-Agreement-Initial-Request-Form in our platform's editor.
  2. 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.
  3. Proceed to the 'Clinical Team Information' section. Input the provider organization name, address, TIN, NPI, and contact details for the clinical team lead.
  4. 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.
  5. Complete any internal use fields as necessary and ensure all required information is accurate before submitting your request.

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