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Get Az Ahp Facility Credentialing & Recredentialing Application Form 2017

Itional sheets when necessary. Type of Facility (As listed on License or Accreditation) Acute Rehab ASC Dialysis DME/Infusion Enteral Family Planning Home Health Hospice Hospital Lab O&P PT/OT/ST Radiology Sleep Center Skilled Nursing Facility Transportation Urgent Care Vision Wound Care Behavioral Health Assisted Living Center Assisted Living Home FQHC Outpatient Medical Rehab Center Other (Please Specify): Facility Demographics Legal Business Name (as reported to the I.

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