You are invited to participate in a survey regarding your experience using the AHCCCS
website. This survey will take approximately two minutes. Your responses will help
us ensure that you have a high quality experience.
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]
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]
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]
Adobe Acrobat Reader is required to view PDF files. This is a free program available
from the Adobe web site. Follow the download directions on the Adobe
web site to get your copy of Adobe Acrobat Reader.
Microsoft offers Word file viewer and converter programs to enable those who do
not have MS-Word or have another version of MS-Word to open and view MS-Word
Download Word file viewer