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.

Tax ID (99-1234567)

Must be formatted as a TIN

Business or Group Name

First Name

Last Name

Job Title

Counties Served

Select at least one

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

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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