Providers

Forms

Last Updated: June 6, 2023 at 1:15 pm

2023 CPT Codes for Supplemental Benefits (Updated - 04/19/2023 10:08 AM)

2023 Supplemental Code Set – Dental (Updated - 03/28/2023 09:21 PM)

Medical Services Prior Authorization Form

Pharmacy Medication Prior Authorization Form (Updated - 02/14/2023 08:42 AM)

Medicare Prescription Drug Coverage and Your Rights (Updated - 12/31/2018 06:21 PM)

Waiver of Liability (WOL) Statement (Updated - 07/30/2023 05:15 PM)

Maternal Health Risk Assessment

Care Management Referral Form (Updated - 04/19/2023 05:45 PM)

Provider’s Coding Toolkit (Updated - 04/18/2023 09:47 AM)

Fraud, Waste and Abuse Referral form (Updated - 07/30/2023 05:23 PM)

Request for Participation – AzAHP Practitioner Data Form (Updated - 06/13/2022 04:57 AM)

Request for Participation – AzAHP Organizational Data Form (Updated - 06/13/2022 04:58 AM)

Provider Roster (Updated - 03/06/2023 02:08 PM)

Practitioner Practice Change Form (Updated - 06/13/2022 05:00 AM)

Prior Authorization and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities (Updated - 11/17/2021 11:09 AM)

BHIF, BHRF, TFC, and SUD BHRF Prior Authorization and Continued Stay Request Form (Updated - 06/06/2023 01:13 PM)

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