Arizona Priority Care - Tax Id Change / Termination Form

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Arizona Priority Care (AZPC)
Provider Tax ID Change / Termination Form
Please complete the applicable information and email or fax to:
Email:
Fax: Attn: Provider Network (480) 499-8729
Tax ID Change
Provider Termination Request
Ancillary Term Request
Current
Group Name: _______________________________________________________________________________
Information:
Tax ID #: ___ ___ ___ ___ ___ ___ ___ ___ ___
Does update apply to all providers under Tax ID?
Yes
No
Please list applicable providers below or attach spreadsheet with required information
Tax ID
Add New Tax ID #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Effective Date: ___ ___/___ ___/___ ___
Change:
Terminate Tax ID #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Term Date: ___ ___/___ ___/___ ___
(attach new W9)
Termination Reason: ________________________________________________________________________
Please note, your Contract Representative will be contacting you to finalize this change.
Provider #1
Provider Name & NPI: _______________________________________________________________________
Term
Effective Date of Term: ___ ___/___ ___/___ ___
Request:
Reason for Term: ___________________________________________________________________________
Reassign Members (PCPs only)?
Yes
No
If yes, provider to reassign to: ______________________________________________________________
Forwarding Information: _____________________________________________________________________
Provider Name & NPI: _______________________________________________________________________
Provider #2
Term
Effective Date of Term: ___ ___/___ ___/___ ___
Request:
Reason for Term: ___________________________________________________________________________
Reassign Members (PCPs only)?
Yes
No
If yes, provider to reassign to: ______________________________________________________________
Forwarding Information: _____________________________________________________________________
Provider Name & NPI: _______________________________________________________________________
Provider #3
Term
Effective Date of Term: ___ ___/___ ___/___ ___
Request:
Reason for Term: ___________________________________________________________________________
Reassign Members (PCPs only)?
Yes
No
If yes, provider to reassign to: ______________________________________________________________
Forwarding Information: _____________________________________________________________________
Provider#4
Provider Name & NPI: _______________________________________________________________________
Term
Effective Date of Term: ___ ___/___ ___/___ ___
Request:
Reason for Term: ___________________________________________________________________________
Reassign Members (PCPs only)?
Yes
No
If yes, provider to reassign to: ______________________________________________________________
Forwarding Information: _____________________________________________________________________
Print Name/Title (person completing this form): _______________________________________________________________
Email Address: _________________________________________________ Phone Number: __________________________
Date: ___ ___/___ ___/___ ___
If you have any questions or want to confirm receipt of fax please call: (480) 499-8700 ext 8241
PN024-1.2 Rev 08/28/15

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