Provider Renewal Form

  • Annual Credentialing Fee $145

  • I authorize the above card to be charged for my credentialing fee.

  • To obtain a copy of our fee schedule/health plan list please e-mail us at
  • You consent to us contacting you using all channels of communication and for all purposes. We will use the contact information you provide to us. This may include text messages, automatic telephone dialing systems, prerecorded voice and/or fax. We do not sell or distribute our lists. This information is used for internal purposes only.
  • PO BOX 71717, PHOENIX, ARIZONA 85050 VOICE 877-311-3338 FAX 602.485.3100
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