You are invited to participate in a survey regarding your experience using the AHCCCS
website. This survey will take approximately two minutes. Your responses will help
us ensure that you have a high quality experience.
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.
The benefits of receiving payments electronically are:
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
Providers must complete the following sections of the form:
Submit the completed form to the following address for processing:
Adobe Acrobat Reader is required to view PDF files. This is a free program available
from the Adobe web site. Follow the download directions on the Adobe
web site to get your copy of Adobe Acrobat Reader.