AHCCCS Provider Registration Packets

Provider Registration 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 Registration Application
  • Provider Registration 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.)  
  • Attestation Form (only applies to providers impacted by A.R.S. 35-196.05)

    • IMPORTANT NOTICE: The United States District Court for Arizona has issued an order permanently enjoining the State from requiring, as a condition of participation in the AHCCCS program, an attestation regarding abortion services as required by A.R.S. § 35-196.05. The State has filed an appeal of that order; however, until and unless the order is reversed, the State will not terminate any current provider agreements based on the attestation or lack of an attestation. Neither will the State deny any applications to register as an AHCCCS provider based solely on the attestation or the lack of an attestation.

• 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 registration 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


• Complete the applicable profile and submit with your application, if registering as one of the following provider types
  
  
  • Attendant Care/Company  
  • Dental Hygienist  
  • 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 Registration Application to update their address on their provider registration file.

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

  • Provider Participation Agreement
  • Re-Enrollment Address Verification Form
  • Re-Enrollment 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
  • 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.

Mail or fax completed and signed registration forms.

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

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

For questions regarding the provider registration process, please contact the AHCCCS Provider Registration Unit.

• Call:
  • In Maricopa County: 602-417-7670 and select option 5
  • Outside Maricopa County: 1-800-794-6862
  • Out-of-State: 1-800-523-0231
• Write:
  
  Arizona Health Care Cost Containment System (AHCCCS)
  ATTN: Provider Registration Unit
  PO Box 25520, MD-8100
  Phoenix, AZ 85002