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 Provder 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.
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.