AHCCCS Provider Enrollment Packets

Provider Enrollment forms are provided in two types of packets:

• Individuals/Companies/Facilities Packet

  Individuals, companies and facilities, must complete all of the following forms. Exceptions are noted.

  • Provider Enrollment Application
  • Provider Enrollment Instructions | Rich Text Version
  • Provider Participation Agreement
  • IRS Form W-9 (required)
    (Please ensure that you enter "W-9" and not "W9" when searching for this form.)
  • Criminal Offense Form (Only individual providers need to complete.)  
  • Disclosure of Ownership Form (Only companies need to complete.)  
• Group Biller Packet

  The Group Billing Packet contains the forms that are required for an organization acting as the financial representative of any provider or group of providers who have authorized the organization to act in their behalf. Entities applying for a group biller number must complete all the following forms in the enrollment packet.

  • Group Biller Registration Form
  • Group Biller Authorization
    • Disclaimer - Please submit a group billing authorization form with your intital registration packet if you would like to be linked to a group id.
  • Group Biller Participation Agreement
  • IRS Form W-9 (required)
    (Please ensure that you enter "W-9" and not "W9" when searching for this form.)
  • Disclosure of Ownership Form


• If registering as one of the following provider types listed below, complete the applicable profile, review any special registration requirements notated by the provider type, and submit with your application.
  
  
  • Attendant Care/Company  

    New - In an effort to process the submission of the Attendant Care provider type documents efficiently, AHCCCS is requiring that the list of employees requested on the second page of the Attendant Care Provider Profile form be provided in an Excel spreadsheet format. This document will substitute the second page of the Provider Type Profile. All applications submitted without the Excel spreadsheet will be pended for the Excel spreadsheet. The format of the excel spreadsheet should follow the format demonstrated in the table below:

    Provider ID	Employee Name	SSN	DOB	Employment Begin date	Employment End Date
    Must be numeric	LastName/FirstName Format	Must be numeric only E.g. 123456789	MM/DD/YY Format	MM/DD/YY Format	MM/DD/YY Format

    Note: All excel spreadsheets must be sent through email.

    PRNotice@azahcccs.gov

  • Affiliated Practice Hygienist  

  NOTE: A dental hygienist may register with AHCCCS only if the dental hygienist has an affiliated practice relationship with a dentist that complies with A.R.S. 32-1281(G) and 32-1289.01. All other dental hygienists may not register with AHCCCS or independently bill Arizona’s Medicaid system for their services.

  • Homemaker(if applying as a company)
  • Independent Testing Facility
  • Non-Emergency Transportation Provider  
    • Complete the Online training module and submit the certificate:
      Non-Emergency Medical Transportation Provider Training CBT
    • Copy of registration for each vehicle is required.
  • Nurse-Midwife
  • Physician Assistant (if a behavioral health medical practitioner)
  • School Based Bus Transportation

  Note: Existing providers may use the Provider Enrollment Application to update their address on their provider enrollment file.

• The following are forms required, if you have received a notice to re-enroll.

  • Provider Participation Agreement
  • Revalidation Address Verification Form
  • Revalidation Address Verification Form Instructions | Rich Text Version
  • IRS Form W-9
    (Please ensure that you enter "W-9" and not "W9" when searching for this form.)
  • Criminal Offense Form (Only individual providers need to complete.)
  • Disclosure of Ownership Form (Only companies need to complete.)

• Provider Type Profiles

  • Attendant Care/Company
  • Affiliated Practice Hygienist  

  NOTE: A dental hygienist may register with AHCCCS only if the dental hygienist has an affiliated practice relationship with a dentist that complies with A.R.S. 32-1281(G) and 32-1289.01. All other dental hygienists may not register with AHCCCS or independently bill Arizona’s Medicaid system for their services.

  • Homemaker(if applying as a company)
  • Independent Testing Facility
  • Non-Emergency Transportation Provider
    • Complete the Online training module and submit the certificate:
      Non-Emergency Medical Transportation Provider Training CBT
    • Copy of registration for each vehicle is required.
  • Nurse-Midwife
  • Physician Assistant (if a behavioral health medical practitioner)
  • School Based Bus Transportation

AHCCCS Provider Address Updates

The Provider Address Update Form is for existing providers to add or change addresses and tax identification numbers on their provider file at AHCCCS.

Click on the appropriate links below:

• AHCCCS Provider Address Update Form
• AHCCCS Provider Address Update Form – instructions
• IRS Form W-9 (required)

NOTE: Registered AHCCCS Providers may change their correspondence address using the AHCCCS online Provider Website.

The Out of State/One-time Waiver of Registration Requirements applies to those out of state providers that offer covered services to AHCCCS members. Certain restrictions apply; see One-time Waiver Requirements and Excluded Cities List below.

• One-time Waiver of Provider Registration Requirements
• Cities & Towns Excluded from the Waiver

Providers, who are excluded from this policy, may register using the standard provider enrollment process.

Mail or fax completed and signed enrollment forms.

• Mail:
  
  AHCCCS Provider Enrollment
  P.O. Box 25520, Mail Drop 8100
  Phoenix, AZ 85002
• Fax:
  Attn: AHCCCS Provider Enrollment
  602 256-1474

Note: All applicable licenses and certifications must be submitted with the enrollment forms. If you have questions regarding the types of applicable licenses or certifications, please contact Provider Enrollment at the phone numbers listed below.

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

• Call:
  • 602-417-7670 Option 5 (calling from Maricopa County)
  • 1-800-794-6862 (calling from in-state, but outside of Maricopa County)
  • 1-800-523-0231 (calling from out of state)
• Write:
  
  Arizona Health Care Cost Containment System (AHCCCS)
  ATTN: Provider Enrollment Unit
  PO Box 25520, MD-8100
  Phoenix, AZ 85002