Create - Provider Submission Portal

NEW SUBMISSION

Need to attach additional documents? Click Here

Switch to Removal Of Designation? Click Here

Applicant Info

First Name*

Middle Name

Last Name*

Date of Birth*

Gender*

Race*

Preferred Pronoun*

Preferred Language*

Is Applicant Experiencing Homelessness?*

Yes No

Applicant Address

City

State

Zip Code*

AHCCCS ID Number

A-

Insurance Type*

Provider Info

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*

Attachments

SMI Consent For Assessment*

Removal Of Designation Attestation Form*

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.

Total File Size:0MB

NEW SUBMISSION

Applicant Info

Evaluation Info

Provider Info

Attachments

Review

Applicant Information

Evaluation Information

Provider Information

Attachments