Az agency title application 2026

1. Click ‘Get Form’ to open the az agency title application in our editor.
2. Begin by entering the 'Date of Application' and your AHCCCS Provider ID # along with your National Provider Identification (NPI) in the designated fields.
3. Fill in your 'Provider Name', 'Phone Number', and 'E-Mail Address'. Ensure that all contact information is accurate for effective communication.
4. Complete the 'Provider Administrative Address' and 'Provider Facility Address' sections, including city, street, state, county, and zip code.
5. Indicate your contracts with T/RBHAs by marking a ‘C’ for current contracts and an ‘I’ for intended contracts.
6. In the 'Services Provided' section, check all applicable services your agency offers for Title XIX Certification. Be thorough to ensure compliance.
7. Attach required enclosures such as incorporation documents and occupancy permits using our platform's upload feature.
8. Finally, review all entries for accuracy before signing as the Program Director and submitting your application.

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