Arizona Priority Care - Demographic Change Form
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1Arizona Priority Care Demographic Update Form
Please complete the applicable information and email or fax to:
Email:
Fax: Attn: Provider Network (480) 499-8729
Name Change
Primary Address Change
Billing Address Change
Add Location
Remove Location
Current
Group/Provider Name: _______________________________________________________________________
Information:
NPI #: ___________________________
Tax ID #: _____________________________
Does update apply to all providers under Tax ID?
Yes
No
If no, please attach roster listing only applicable providers
Name
New Provider Name:
Change:
(If applicable)
New Group Name (attach new W9):
Effective Date: _____/_____/_______
New Primary
Street: ______________________________________________________________________ Suite #: _________
Address:
City: ________________________________ State: ________ ZIP Code: _________________
Telephone: _________________________ Fax: ________________________
Should the previous primary address be removed or kept as a secondary location?
Remove
Secondary Location Comments:
Effective Date: _____/_____/_______
New Billing
Street: ___________________________________________________________________ Suite #: _________
Address:
City: ________________________________ State: ________ ZIP Code: _________________
(Attach new W9)
Telephone: _________________________ Fax: ________________________
Effective Date: _____/_____/_______
New
Street: ___________________________________________________________________ Suite #: _________
Correspondence
City: ________________________________ State: ________ ZIP Code: _________________
Address:
Telephone: _________________________ Fax: ________________________
Effective Date: _____/_____/_______
New Additional
Street: ___________________________________________________________________ Suite #: _________
Location:
City: ________________________________ State: ________ ZIP Code: _________________
(If applicable, attach
Telephone: _________________________ Fax: ________________________
page for additional
locations)
Effective Date: _____/_____/_______
Remove
Street: ___________________________________________________________________ Suite #: _________
Location:
City: ________________________________ State: ________ ZIP Code: _________________
(If applicable, attach
Telephone: _________________________ Fax: ________________________
page for additional
locations)
Signature: _______________________________ Print Name/Title: ______________________________________________
Email Address:_______________________________________________________________ Date: _____/_____/_______
If you have any questions or want to confirm receipt of fax please call: (480) 499-8700 ext 8241
PN023 – 1.1 Rev 08/28/2015
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Parent category: Medical