Client Information

* For decertification enter current (T)RBHA
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Provider Information

Provider contact for packet submission questions.
Separate multiple email addresses with a semicolon and a space
CRN will contact this individual to clinically staff the application. i.e. - treating prescriber, BHMP, etc.

Separate multiple email addresses with a semicolon and a space

Having trouble submitting packets via this portal? Please call 602-527-8115. You may submit via fax at 844-611-4752 – however, please ensure you have all the required forms listed above under 'Complete Application'.