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Get Ahcccs Ach Vendor Authorization Form

M.D. 5400, P.O. BOX 25520, PHOENIX, AZ. 85002-5520 AHCCCS Finance Section Fax # 602-258-5943 AHCCCS Website: www.azahcccs.gov SECTION 1 Transaction Type Check the applicable transaction(s) and complete the sections indicated. Please complete Section 2 and 3 below; your financial institution must complete Section 4 prior to returning the form to AHCCCSA. New ACH Setup: Change Account Type: Change Account Number: Change Financial Insti.

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