AHCCCS Data Access Forms

Electronic Data Exchange Request Form

The Electronic Data Exchange Request Form is intended for use by providers and vendors who need to request an electronic data exchange account for the AHCCCS electronic file transfer (EFT) server. If requesting a new account, this form must be accompanied by a signed External User Affirmation Statement.

Electronic Data Exchange Request Form [Word, 95KB]

External User Affirmation Statement

The External User Affirmation Statement is an agreement signed by external users who have access to the AHCCCS computer network and data. Users who sign this statement are agreeing to abide by all applicable laws, rules and AHCCCS directives.

External User Affirmation Statement [PDF, 16KB]

User Access Request Form

The User Access Request Form is used by ISD Data Security to gather the information and authorization necessary to grant external users access to data on the AHCCCS computer systems. If requesting a new account, this form must be accompanied by a signed External User Affirmation Statement.

User Access Request Form [Word, 61KB]