Provider Registration
To enroll in the Arizona Medicaid Program as a provider
of services, click on the links below to obtain all necessary forms and
instructions.
The registration forms must be completed, signed and mailed
to AHCCCS Provider Registration, P.O. Box 25520 Mail Drop 8100 Phoenix, AZ
85002. Existing providers may fax address updates to (602) 256-1474.
For
further questions regarding registration, please call the AHCCCS Provider
Registration Unit at (602) 417-7670, option #5. The in-state toll free
number is 1-800-794-6862. The out-of-state toll free number is
1-800-523-0231.
Please note: Effective March 1, 2007, the National Provider
Identifier will be required prior to registration. This applies to all
applicable providers.
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Provider Registration Packet
Click
Here to download the Provider Registration Packet files
in a ZIP compressed file archive. (588KB)
These files are provided in PDF
format. They can be either be completed online and then printed,
or printed then completed offline.
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Group Biller Packet
Related Forms
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Note: All applicable licenses and
certifications must be submitted with the registration forms. If
registering as one of the following provider types, please contact
the Provider Registration Unit before mailing your application:
Independent Testing Facilities, Nurse Midwife, Physician
Assistant, Personal Care Attendant-Companies only, Non-Emergency
Transportation-Companies only, Homemaker-Companies only, School
Based Bus Transportation and School Based Attendant Care. (These
provider types require additional forms)
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