Potential Provider Application


Facility Information

AHCCCS Registered *

For those organizations without an AHCCCS ID, click here to identify your Provider Type.


Populations Served


Please include a short description of specific treatment services and programs offered and include in your packet any marketing materials to present to the committee. Be sure to highlight how your agency/programs are different or unique from other agencies in your provider type.

Contact Information

Additional Information

Do you Have an Electronic Medical Record *

Are you a Medicare Provider *

Do your staff bill under the same Tax ID number (TIN)? *

Attestation *