AHCCCS Application Request

Download a PDF version of the AHCCCS application immediately, or, complete the form below and a printed version of the application will be mailed to you in a few days.

NOTE: This application does not apply for individuals who are in need of Arizona Long Term Care Services (ALTCS), such as home health care, nursing facility care, or assisted living. To apply for ALTCS, applicants must contact one of our ALTCS offices.

Enter Your Application Request Information First Name:
Last Name:
Address:
City:
State: Zip Code:

Application Type: Number Requested: Language:

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AHCCCS, 801 E. Jefferson, Phoenix, AZ 85034, (602) 417-4000

Send your Member and Provider questions and comments to the Public Information Office.

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