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 (This enrollment type acts as a “Group Biller Only” provider type 01 (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

Licensing for Provider Types Requiring a Certificate & Transmittal

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.

Provider Type Profile Attestations

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.”

Affiliated Practice Hygienist Link
(PT-40) Attendant Care

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

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
(PT-NE) NEMT Equine
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

Fax: (602) 256-1474

Who to Contact with Questions

For questions regarding the provider enrollment process, please contact the AHCCCS Provider Assistance.

Email: APEPTrainingQuestions@azahcccs.gov

Phone:

Maricopa County: (602) 417-7670 option 5

Outside Maricopa County: 1-800-794-6862

Out-of-State: 1-800-523-0231