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.

ACH Vendor Authorization Form [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.

Providers must complete the following sections of the form:

  • Section 1 - Identify the transaction type
  • Section 2 - Provide payee information
  • Section 3 - Provide signature authorization for setups, changes, or cancellations
  • Section 4 - Financial Institution, must be completed and signed by a representative of the provider's financial institution or bank.

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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