Report Concerns About the Quality of Care Received

AHCCCS is committed to ensuring that all members receive quality health care and are able to access services. If you or any AHCCCS member has experienced a barrier to getting health care services or have concerns about the quality of services received, please report it to Clinical Quality Management (CQM) by completing this form, calling (602) 417-4885 or by emailing CQM@azahcccs.gov

Submit concerns that include (but are not limited to): the inability to receive health care services; concerns about the quality of care received; issues with health care providers or health plans; or timely access to services. Use the “Type of Issue” drop down list at the bottom of this page to choose the most appropriate category.

Submitter Information

* Denotes a required field

First Name:

Last Name:

Phone Number:

Email:

Relationship To Member:

Referred By:

Member Information

Note: Please enter Member's First Name and Last Name, and/or Provider Name in order for us to follow up with you:

Member's First Name:

Member's Last Name:

Member ID:

Member's Date Of Birth:

Coverage Type:

Health Plan:

Provider Information

Provider Name:

Provider ID:

Information About This Issue

Street:

City:

State:

Zip:

County:

Service Type: *

Preferred Contact Method:

Type Of Issue: *

Please Describe the Issue: *

+

Hi! I'm AVA, the AHCCCS Virtual Assistant.

Click me for assistance.

Can't find what you're looking for? Please visit the AHCCCS Document Archive.

Back To Top