Provider Enrollment Application
The AHCCCS Provider Enrollment Application form is a universal application required to enroll, revalidate, or modify a provider id. The form should only be used if the provider has extenuating circumstances to support the ability to utilize the online AHCCCS Provider Enrollment Portal System (APEP). Circumstances should be outlined in a written statement along with submission of the AHCCCS Provider Enrollment Application form to avoid delays in processing.
The application is for all enrollment types:
- Individual/Sole Proprietor or Rendering Servicing.
- Group Biller (An organization electing to act as a financial representative for any provider or group of providers).
- Facility/Agency/Organization (e.g., Hospital, Nursing Facility, Various Entities).
- Contractor/MCO.
- Atypical (non-medical) Individual or Agency.
AHCCCS Provider Enrollment Application form (contains Provider Participation Agreement)
IRS W-9 (required)
(Note: On the IRS web page Search “W-9” to obtain the correct form)
For a complete list of provider to types aligning to enrollment types refer to the Provider Enrollment Screening Glossary
Provider Type Profile Attestations
If enrolling as one of the following provider types listed below, the additional Provider Type Profile is required, review the special instructions outlined by the provider type, submit with the AHCCCS Provider Enrollment Application form, or follow the instructions to submit in APEP.
- Affiliated Practice Hygienist Link
- (PT-40) Attendant Care
- The Provider Type 40 Attendant Care Provider Type Profile is required to be downloaded, signed/dated by the Owner/Provider, and uploaded directly in AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type – License” under the “Document Name – AHCCCS Provider Registration”.
- Employee information is uploaded in APEP under Employee Details. Template instructions are outlined in the Employee Details step.
- Homemaker (Applying as a company)
- Independent Testing Facility
- (PT-28) Non-Emergency Transportation Company
- Refer to the Provider Type 28 Non-Emergency Transportation Provider Type Profile for a complete list of requirements.
- The Provider Type 28 Non-Emergency Transportation Provider Type Profile is required to be downloaded, signed/dated by the Owner/Provider, and uploaded directly in AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type – License” under the “Document Name – AHCCCS Provider Registration”.
- Employee/Driver information is uploaded in APEP under Employee Details. Template instructions are outlined in the Employee Details step.
- (PT-NT) Non-Emergency Transportation Network Company
- The Provider Type NT Transportation Network Company Provider Type Profile is required to be downloaded, signed/dated by the Owner/Provider, and uploaded directly in AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type – License” under the “Document Name – AHCCCS Provider Registration”.
- (PT-NE) NEMT Equine
- The Provider Type NE NEMT Equine Provider Type Profile is required to be downloaded, signed/dated by the Owner/Provider, and uploaded directly in AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type – License” under the “Document Name – AHCCCS Provider Registration”.
- Nurse Midwife
- Physician Assistant (behavioral health medical practitioner)
- School Based Bus Transportation
Where to Send Completed Forms
Email or Fax completed and signed forms.
Email: PRNotice@azahcccs.gov
OR
Fax: (602) 256-1474
Who to Contact with Questions
For questions regarding the provider enrollment process, please contact the AHCCCS Provider Assistance.
Email: PRNotice@azahcccs.gov
OR
Phone:
Maricopa County: (602) 417-7670 option 5
Outside Maricopa County: 1-800-794-6862
Out-of-State: 1-800-523-0231
