AHCCCS Provider Registration Packets

The Provider Registration process is required those who provide medical care services (including primary care doctors, transportation, etc) to AHCCCS beneficiaries.

• Registration Packets
• Where to Send Completed Forms
• Who to Contact with Questions

Registration Packets

Note: Information provided in PDF files.

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 [132KB]
  • Provider Registration Instructions [123KB]
  • Provider Participation Agreement [38KB]
  • 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.) [40KB]
  • Disclosure of Ownership Form (Only companies need to complete.) [139KB]
  • Disclosure of Ownership Instructions [18KB]

  Note: Existing providers may use the Provider Registration Application to update their address on their provider registration file.

• 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 [142KB]
  • Group Biller Authorization [78KB]
  • Group Biller Participation Agreement [43KB]
  • IRS Form W-9 (required)
    (Please ensure that you enter "W-9" and not "W9" when searching for this form.)

Where to Send Completed Forms

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 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.)

Who to Contact with Questions

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