Arizona Foundation for Medical Care Provider Change Form

Provider Name - Please list current Provider Information

Last Name:

Primary:

Specialty Change

Please note: Provider is entirely responsible for keeping AFMC informed about current practice information. If AFMC does not receive updated information from the provider in writing, AFMC will continue to send correspondence to the addresses currently in our database. AFMC will not responsible for lost or returned mail if we do not receive this completed form from the provider at least five (5) days prior to the effective date of change. Please complete all applicable information, including REQUIRED fields (required fields are in red). Failure to complete required fields may result in the request not being processed. Please allow 5-7 business days for this request to be processed. If you should have any questions, please contact AFMC's Marketing & Network Management Department at 800-624-4277.

MI:

Secondary:

Board Certified

Board Certified

Tax ID Change

No

No

Yes (Req. Documentation)

Yes (Req. Documentation)

326 E. Coronado Rd. Phoenix, AZ 85004 602-252-4042 or 800-624-4277 www.azfmc.com networkmanagement@azfmc.com

Type of Change

Tax ID #:

First Name:

Corp Name:

AZ License #:

Termed TIN#:

New/Replacement TIN#:

Effective Date:

If you select other, please list your type of change here:

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New/Additional TIN#:

Effective Date:

Effective Date:

Reason for TIN Term/Change:

To fax this form to AFMC, please follow these easy steps: 1. Fill out the form.

2. Click the print button.

3. Sign the form and fax it to: AFMC Marketing & Network Management at 602-495-8684.

Signature:

Date:

Address - Please make sure to list phone and fax numbers. Also, please note that as of September 1, 2010, AFMC requires that all addresses must have a full zip code, including zip +4. Each physician must also have at least one physical address. Therefore, P.O Boxes will no longer be accepted as a physician's only active address.

BillingMailingOfficeAddTerm

Phone Number: Fax Number:

Address:Tax ID:

City: State:

BillingMailingOfficeAddTerm

Phone Number: Fax Number:

Address:Tax ID:

City: State: Zip Code + 4:

BillingMailingOfficeAddTerm

Phone Number: Fax Number:

Address:Tax ID:

City:

BillingMailingOfficeAddTerm

Phone Number: Fax Number:

Address:Tax ID:

City:

last updated 10.8.10

E-mail Address:

Zip Code + 4:

Zip Code + 4:State:

Zip Code + 4:State:

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