Submit a Provider Interest Form and attach the required AzAHP forms.
Attach the appropriate AzAHP form(s) to the Provider Interest Form only after AHCCCS Registration is completed. Include the documents requested on page 1 of the AzAHP form with your Provider Interest Form. Without the necessary documents, a contracting decision cannot be made.
Need help with your AzAHP forms? The highlighted forms below illustrate mandatory fields you must complete.
Check out these helpful tip sheets for guidance:
If you are a behavioral health provider, please submit a Provider Interest Form only if you are interested in participating with Banner Medicare Advantage, AHCCCS Complete Care (ACC), Arizona Long Term Care System (ALTCS), or the Dual Special Needs Plan (Banner Dual). If you are interested in participating with Banner|Aetna, Aetna, United Healthcare or Blue Cross Blue Shield of Arizona products, you need to contact the health plan directly. Banner does not contract for behavioral health services for Banner Health Network products.
Behavioral Health providers should include a summary description of programs, including target populations and age categories, specific models of care/therapies used, along with frequency of programming treatment and complete Exhibit E for each location. See link to instructions and form below.
If you have contract-related inquiries, questions or need to provide additional supporting documentation, please email [email protected]. Please allow 120 days before requesting status on a new contract. Please include the name of your organization and tax identification number in your email.