Create - Provider Submission Portal

First Name*

Middle Name

Last Name*

Date of Birth*

Is Applicant Experiencing Homelessness?*

Yes No

Applicant Address

City

State

Zip Code*

Region*

RBHA*

AHCCCS ID Number

Insurance Type*

Gender*

Race*

Preferred Pronoun*

Preferred Language*

Provider*

Assessor Name*

Assessor Credentials*

Packet Submission Contact*

Packet Submission Phone*

Ext.

Packet Submission Email* Please provide a valid work email

Same As Packet Submission Info

Clinical Contact Name*

Clinical Contact Direct Phone*

Ext.

Clinical Contact Email*

SMI Consent For Assessment*

Waiver of Three Day Determination Form

SMI Determination Form*

Core Assessment*

Other Documents Can submit multiple files here. To do so, when the file selector opens hold ctrl and start selecting the files that you want.

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