Order AHCCCS Applications in Bulk

The fastest way to apply for AHCCCS is to apply online at Health-e-Arizona. Information about becoming a Health-e-Arizona Community Partner is available here.

NOTE: Bulk material requests for the Baby Arizona program may be submitted from the Baby Arizona website.

Contacts

If you have questions, please email Patty.Dennis@azahcccs.gov.

Please Enter Order Amounts

Application Types	Amounts
Application for AHCCCS Health Insurance (AH-001) - English
Application for AHCCCS Health Insurance (AH-001) - Spanish

Please Enter Contact Information

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*Which category below best describes your organization?
Health Care Advocate
Health Care Provider
School
Sister Agency (i.e. DES, DHS)
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Other If other, please explain:

Contact First Name:
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Contact Last Name:
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Contact Title: (if applicable)

Contact Address 1:
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Contact Address 2: (if applicable)

City:
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ZIP Code: (xxxxx-xxxx, last four optional) *

Contact E-Mail Address:
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Contact Phone Number:
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Please explain how you will use these materials, and be specific:
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