Provider Enrollment Application 
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Provider Enrollment Application

Welcome to the Arizona Health Care Cost Containment System (AHCCCS) Provider Enrollment form. This is a universal form required to enroll, re-enroll/revalidate, or to submit a modification request.

Individuals/Companies/Facilities

This application is for Individual/Sole Proprietor, Rendering/Servicing, Atypical Individual, Group Practice, Contractor/MCO, Facility/Agency Organization (FAO), and Atypical Agency provider types. For a complete list of provider to types to enrollment types refer to the Provider Enrollment Screening Glossary

AHCCCS Provider Enrollment form

IRS W-9 (required)

(Note: On the IRS web page Search “W-9” to obtain the correct form)

If enrolling as one of the following provider types listed below, the additional provider type profile is required, review any special requirements notated by the provider type, submit along with your paper application.

Attendant Care/Company

Note: In effort to process the submission of the Attendant Care Company’s employees efficiently, AHCCCS is requesting an Excel spreadsheet of the company’s employees. Please refer to the instructions below for requirements, formatting and delivery method of the document.

Excel Spreadsheet Required;

Include: Provider ID; Employee Name, SSN, DOB, Employment Begin Date, Employment End Date;

Email Excel Spreadsheet: PRNotice@azahcccs.gov (document cannot be accepted through Fax or Mail)

Where to Send Completed Forms

Email or Fax completed and signed forms.

Email: PRNotice@azahcccs.gov

OR

Fax: (602) 256-1474

Who to Contact with Questions

For questions regarding the provider enrollment process, please contact the AHCCCS Provider Enrollment unit.

Email: PRNotice@azahcccs.gov

OR

Phone:

Maricopa County: (602) 417-7670 option 5

Outside Maricopa County: 1-800-794-6862

Out-of-State: 1-800-523-0231

Can't find what you're looking for? Please visit the AHCCCS Document Archive.
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