AzAHP Non-Delegated Roster and Practitioner Change Forms
Applicable to: Mercy Care Complete Care, Mercy Care ACC-RBHA, Mercy Care Long Term Care, Mercy Care DD, Mercy Care DCS-CHP and Mercy Care Advantage
Effective immediately, new credentialing forms are available for providers to update various AHCCCS plans that have been approved for credentialing by the AzAHP Alliance. These forms are also posted to their website, which is available by clicking on their link. Mercy Care has also posted these forms to our Provider Forms web page for your convenience. The forms are as follows:
Practitioner/Practice Change Form - This form is specifically designed for quick notification of provider terms and changes for one provider at a time. This form will be beneficial for smaller groups that do not have a lot of movement but can be used by all providers for changes.
Non-Delegated Group AZAHP Roster - This form is an official group roster that is beneficial to larger groups to provide notification of adds, terms, and changes for multiple providers in their practice all at once, however, it can be used by all providers to provide change notices. This roster will be utilized for credentialing as well.
As a friendly reminder:
All forms need to be completed to their entirety. If a field does not apply, please mark as "n/a" in that field.
All terminations must be reported 90 days prior to the termination of the provider or group.
