Welcome to the Arizona Health Care Cost Containment System (AHCCCS) Provider Enrollment form. This is a universal form required to enroll, re-enroll/revalidate, or to submit a modification request.
Individuals/Companies/Facilities
This application is for Individual/Sole Proprietor, Rendering/Servicing, Atypical Individual, Group Practice, Contractor/MCO, Facility/Agency Organization (FAO), and Atypical Agency provider types. For a complete list of provider to types to enrollment types refer to the Provider Enrollment Screening Glossary
AHCCCS Provider Enrollment form
IRS W-9 (required)
(Note: On the IRS web page Search “W-9” to obtain the correct form)If enrolling as one of the following provider types listed below, the additional provider type profile is required, review any special requirements notated by the provider type, submit along with your paper application.
Note: In effort to process the submission of the Attendant Care Company’s employees efficiently, AHCCCS is requesting an Excel spreadsheet of the company’s employees. Please refer to the instructions below for requirements, formatting and delivery method of the document.
Excel Spreadsheet Required;
Include: Provider ID; Employee Name, SSN, DOB, Employment Begin Date, Employment End Date;
Email Excel Spreadsheet: PRNotice@azahcccs.gov (document cannot be accepted through Fax or Mail)
Email or Fax completed and signed forms.
Email: PRNotice@azahcccs.gov
OR
Fax: (602) 256-1474
For questions regarding the provider enrollment process, please contact the AHCCCS Provider Enrollment unit.
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
