Provider Comms Distribution List Registration

Provider Comms Distribution List Registration

Attestation*

By filling out this form, I confirm that I am a key contact person for my organization. As a key contact person, I can make operational decisions for this organization and/or I can and will distribute critical information to persons with decision-making power. I acknowledge that I am opting in to receive provider communications from Arizona Complete Health which may be distributed from a third party. The content of these emails, letters, and/or faxes include but are not limited to regulatory news, training information, claims systems updates, and operational changes.

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Tax ID (99-1234567)*

Must be formatted as a TIN

Business or Group Name*

First Name*

Last Name*

Job Title*

Email*

Counties Served*

Select at least one

Select

For which line of business do you wish to receive information?*

Select

Thank you for submitting your contact information.

You will added to the distribution list within 72 hours. You can view provider communications at our website, https://www.azcompletehealth.com/providers/provider-news.html.

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