Forms

Applications

• Application for AHCCCS Health Insurance - English (PDF)
• Application for AHCCCS Health Insurance - Spanish (PDF)
• Medicare Cost Sharing Programs Application - English (PDF)
• Medicare Cost Sharing Programs Application - Spanish (PDF)
• KidsCare Application

Provider Registration
This section contains information and forms to enroll in the Arizona Medicaid Program as a provider of services. Forms available in this section include:

• Provider Registration Packet
• Group Biller Packet
• One-Time Waiver of Registration Requirements
• Provider Address Update Form

Reinsurance
This section contains information and forms for health plans and program contractors concerning reinsurance under the AHCCCS acute care and ALTCS long term care programs. Forms available in this section include:

• Reinsurance Action Request Form
• Transplant Outlier Template
• Transplant Stage Invoice Cover Sheet
• Transplant Transportation Lodging Form

Security Forms

• User Access Request Form [MS-Word, 55 Kb]
• User Affirmation Statement [PDF, 25 Kb]
  [Updated: December 2007]

Tracking Forms

• Early and Periodic Screening Diagnosis and Treatment Tracking Forms
• AHCCCS Medicare Research Request Form  [PDF, 168 Kb]

Vendor Forms

• ACH Vendor Authorization Form [PDF, 19 Kb]
• Baby Arizona Participating Provider Agreement Form [PDF, 83 Kb]