Contract Request and Information Form
For Medical Providers
Complete the form in few easy steps. Let's get started!
What you will need to complete this request form:
Your CAQH Provider ID. If you don't have one, visit
NPI (National Provider Identifier) Number-you should have one for your own individual use and your group should have one for the organization. For more information, see the federal
National Plan & Provider Enumeration System (NPPES) website.
Arizona State License Number-Include the date you were first licensed to practice in Arizona.
DEA (Drug Enforcement Administration) Registration Number (if applicable)-if you are not registered, visit the
federal DEA registration website.
If you are a PT/ST/OT professional and are part of a group, your group must have a
contract on file
with us before we can complete your credentialing.
You'll need a few minutes to complete the form in its entirety before you submit. You will not be able to save a partially filled out form to finish at a later time.