Sign Up for Direct Deposit

The electronic payment option processes payments using the Automated Clearing House (ACH). This method enables providers to receive reimbursement more quickly than issuing a check. The Arizona Clearing House Association (ACHA) processes the payment directly to the provider's bank account through Bank of America, which functions as the State servicing bank.


Benefits of Receiving Payments Electronically

The benefits of receiving payments electronically are:

  • Immediate availability of funds
  • Fully traceable payments
  • Elimination of mail and deposit delays
  • Elimination of lost, stolen, or misplaced checks

Automated Clearing House (ACH) Vendor Authorization Form

The ACH Vendor Authorization form is used by providers to begin receiving electronic Fee-For-Service reimbursement. You may complete and submit the form yourself by going to:

AHCCCS Online

This is where providers go to check claims' status or to submit claims electronically. Once logged in, click on EFT ENROLLMENT on the top-left of the screen.

Electronic Funds Transfer Authorization Agreement Form [PDF]
Electronic Funds Transfer Authorization Agreement Instructions [PDF]

Note: This form may be filled out online and faxed to AHCCCS Finance Section, Fax Number 602-258-5943, however since an original signature is required, please mail the original form to the address at the bottom of the screen.


ACH Vendor Authorization Form Processing: Mailing Address

Submit the completed form to the following address for processing:

Arizona Health Care Cost Containment System (AHCCCS)
Finance Department, MD 5400
PO Box 25520
Phoenix, AZ 85002

 

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