Arizona Health Care Cost Containment System Forms
The Arizona Health Care Cost Containment System (AHCCCS) is a state government program in Arizona that provides health care services to low-income individuals and families. It is designed to ensure accessibility to medical care, including doctor visits, hospital stays, prescription drugs, and other necessary services, for those who qualify based on income and other eligibility criteria. AHCCCS aims to improve the health outcomes of Arizona residents, particularly those who cannot afford private health insurance.
Documents:
106
PDF 
Word
This Form is used for creating a case for initial dialysis treatment in Arizona.
This Form is used for requesting medication in the state of Arizona. It is used by patients to submit their medication requests to healthcare providers.
This Form is used for obtaining prior authorization for medications at IHS and 638 Tribal Facilities/Pharmacies in Arizona.
This Form is used for requesting Fee-For-Service authorization in Arizona.
This Form is used for correcting prior authorization information in Arizona.
This document is used for certifying the need for Level I facilities in the state of Arizona.
This document is used for recertifying the need for certain benefits or services in Arizona.
This Form is used for authorizing Ahcccs to disclose your protected health information. It is specific to Arizona and is in large print.
This form is used for authorizing the disclosure of protected health information to Ahcccs in Arizona. It is specifically designed for individuals who require large print for readability purposes.
This document is used for disclosing any conflicts of interest in the state of Arizona.
This form is used for requesting prior authorization for medications in the Arizona Fee-for-Service Drug program.
This document is used as a cover sheet for an invoice related to transplant stage services in Arizona.
This document is a template used in Arizona for conducting behavioral analysis. It assists in analyzing and understanding various behaviors in a systematic manner.
This type of document is used for applying for enrollment as a homemaker provider in the state of Arizona.
This form is used for applying for provider enrollment as an attendant care company in the state of Arizona.
This document is for hygienists affiliated with a practice in Arizona who are applying for provider enrollment. It is used to gather information and enroll the hygienist with the relevant healthcare provider.
This document is used to apply for enrollment as a non-emergency transportation company in Arizona.
This document is used for applying for enrollment as a provider of non-emergency medical transportation (NEMT) services for equine patients in the state of Arizona.
This Form is used for applying for enrollment as a non-emergency transportation company network in Arizona.
This form is used for applying to become a provider of school-based bus transportation services in Arizona.
This document is used to enroll as a healthcare provider in Arizona if you are located out-of-state.
This document is a template for helping a child adjust to being placed in a new home in Arizona.
This document is used for nurse-midwives in Arizona to apply for enrollment with healthcare providers.
This Form is used for applying to become an independent testing facility in the state of Arizona.
This type of document is a daily trip report used in Arizona for recording and reporting trips related to AHCCCS, which stands for Arizona Health Care Cost Containment System. It is likely used by providers or agencies to document various healthcare-related trips.
This Form is used for submitting a formal request for tribal consultation in Arizona. It allows individuals or organizations to engage in meaningful dialogue with Native American tribes regarding decisions that may affect tribal lands, resources, or cultural heritage. Tribal consultation is a crucial process for ensuring the protection of Native American rights and interests.
This Form is used for requesting an application to be considered for the American Indian Medical Home Program in Arizona.
Arizona Health Care Cost Containment System American Indian Medical Home Registration Form - Arizona
This Form is used for registering American Indians for medical home services provided by the Arizona Health Care Cost Containment System.
This form is used for spouses in Arizona to acknowledge their understanding of attendant care.
This document is an attestation related to a boycott of Israel in the state of Arizona. It may require individuals or organizations to confirm their compliance or non-compliance with a boycott of Israel.
This document shows the offeror's intention to submit a bid for a project or contract in the state of Arizona.
This document is an attestation form used in the state of Arizona regarding the boycott of Israel.
