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 Provider Registration process is required those
who provide medical care services (including primary care doctors, transportation,
etc) to AHCCCS beneficiaries.
Provider Registration forms are provided in two types
Individuals, companies and facilities, must complete all of the following forms.
Exceptions are noted.
IMPORTANT NOTICE: The United States District Court for Arizona has
issued an order permanently enjoining the State from requiring, as a condition of participation in the AHCCCS
program, an attestation regarding abortion services as required by A.R.S. § 35-196.05. The State has filed
an appeal of that order; however, until and unless the order is reversed, the State will not terminate
any current provider agreements based on the attestation or lack of an attestation. Neither will the State
deny any applications to register as an AHCCCS provider based solely on the attestation or the lack of an
Note: Existing providers may use the Provider Registration Application to update
their address on their provider registration file.
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.
The following are forms required, if you have received a notice to re-enroll.
Provider Type Profiles
Mail or fax completed and signed registration forms.
Note: All applicable licenses and certifications must be submitted with the registration forms. If you
have questions regarding the types of applicable licenses or certifications, please contact Provider
Registration at the phone numbers listed below.
For questions regarding the provider registration process, please contact the AHCCCS Provider Registration Unit.
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.