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:
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
If enrolling as a behavioral health provider, Arizona Department of Health Services will issue a Certificate & Transmittal (C&T) upon request along with the state license. The C&T is required for behavioral health providers issued a license in Arizona, as it identifies the provider type the applicant should enroll under. The Behavioral Health Provider Types pdf identifies which provider types require the C&T. For additional questions regarding the C&T, visit Arizona Department of Health Services or contact the Office of Medical Facilities at 602-364-3030.
If enrolling as one of the following provider types listed below, the additional Provider Type Profile is required as part of the enrollment process. Review the "Special instructions" section outlined in the Provider Type Attestation form, download the form, sign/date, and upload it in the AHCCCS Provider Enrollment Portal (APEP) under the Upload Document step as “Document Type-License” under “Document Name-AHCCCS Provider Registration.”
Email or Fax completed and signed forms.
Fax: (602) 256-1474
For questions regarding the provider enrollment process, please contact the AHCCCS Provider Assistance.
Maricopa County: (602) 417-7670 option 5
Outside Maricopa County: 1-800-794-6862