Report Concerns About the Quality of Care Received

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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 [email protected]

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: *

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