Forms Library

Whether you need to file a claim, inform us of a change of address or request prior authorization for a treatment, filling out the necessary forms will help us respond to your needs quickly and efficiently. Just click on the appropriate form name below to get started. Please remember to submit EFT and ERA forms via secure e-mail or fax – do not mail EFT and ERA forms.

Provider Manual Forms and Attachments

Advanced Directives Resources (English)  Document Date:  06/04/2018  NEW

Advanced Directives Resources (Spanish)  Document Date:  06/04/2018  NEW

AETNA Family Planning Remit Format - Check  Document Date:  06/04/2018  NEW

AETNA Family Planning Remit Format - EFT  Document Date:  06/04/2018  NEW

AHCCCS Contracted Health Plans Behavioral Health Coordinators  Document Date:  06/04/2018  NEW 

Authorization Criteria Adult SMI Behavioral Health Residential Facility   Document Date:  06/04/2018  NEW

Authorization Criteria for Behavioral Health Residential Facility Children/Adolescent  Document Date:  06/04/2018  NEW

Authorization Criteria for Home Care Training for the Home Care Client (HCTC) Children/Adolescent  Document Date:  06/04/2018  NEW

Collaborative Protocol with Adult Probation  Document Date:  06/05/2018  NEW

Collaborative Protocol for Coordination of Care with UnitedHealthcare's Children's Rehabilitative Services (CRS) Programs  Document Date:  06/05/2018  NEW 

Collaborative Protocol with Department of Child Safety  Document Date:  06/05/2018  NEW 

Collaborative Protocol with Department of Economic Security/Division of Developmental Disabilities (DES/DDD) - Child and Adult  Document Date:  06/05/2018  NEW  

Collaborative Protocol with Maricopa County Juvenile Probation Department  Document Date:  06/05/2018  NEW 

Collaborative Protocol with Phoenix VA Health Care System (PVAHCS)  Document Date:  06/05/2018  NEW

Collaborative Protocols with RSA District I  Document Date:  06/05/2018  NEW 

Collaborative Protocol with the Arizona Department of Corrections  Document Date:  06/05/2018  NEW 

Crisis Intervention Services Delivered in Emergency Departments  Document Date:  06/11/2018  NEW

Electroconvulsive Therapy (ECT) Medical Necessity Criteria  Document Date:  06/11/2018  NEW

Mercy Maricopa Remit Format for Check  Document Date:  06/11/2018  NEW

Mercy Maricopa Remit Format for EFT  Document Date:  06/11/2018  NEW

Provider Course Equivalency  Document Date:  06/11/2018  NEW

Provider Deliverables  Document Date:  06/11/2018  NEW

Provider Deliverables Peer Support Specialist/Recovery Support Specialist Assignment Roster   Document Date:  06/11/2018  NEW

Psychological and Neuropsychological Testing Medical Necessity Criteria  Document Date:  06/11/2018  NEW

T/RBHA Acute Health Plan and Provider Coordinator Contact Information  Document Date:  06/11/2018  NEW

 

ACT Exit Criteria Screening Tool Form  Document Date:  06/13/2018  NEW

ACT-RBHA RSA/VR Referral Coordination Form  Document Date:  06/13/2018  NEW 

ACT Team Residential/Flex Care/CLP with Outside ACT Supports Supplemental Form  Document Date:  06/13/2018  NEW

Adult HCTC Application  Document Date:  06/13/2018  NEW

Advanced Directive Form (English)  Document Date:  06/13/2018  NEW

Advanced Directive Form (Spanish)  Document Date:  06/13/2018  NEW

AzAHP Facility Credentialing and Recredentialing Application  Document Date:  06/12/20188  NEW

AzAHP Organizational Data Form  Document Date:  06/12/2018  NEW

AzAHP Practitioner Data Form  Document Date:  06/12/2018  NEW

AzAHP Provider Roster Template  Document Date:  06/12/2018  NEW

Bed Bugs Treatment Process Checklist  Document Date:  06/12/2018  NEW 

Bed Bugs Treatment Service Ticket  Document Date:  06/12/2018  NEW 

Bed Hold or Therapeutic Leave Request for Level I RTC  Document Date:  06/12/2018  NEW

Biohazard Cleaning Request  Document Date:  06/12/2018  NEW

Business Continuity and Incident Management Plan Checklist  Document Date:  06/20/2018  NEW

Certification of Need (CON)  Document Date:  06/20/2018  NEW

Child and Adolescent 45 Day Clinical Review for Continued Prior Residential Facility  Document Date:  06/20/2018  NEW

Child and Adolescent 60 Day Clinical Review for Continued Stay Prior Authorization of HCTC  DocDate;  06/20/2018 NEW

Complex Case Review Form  Document Date:  06/20/2018  NEW

Consent for Assessment for Level of Care (English)  Document Date:  06/20/2018  NEW

Consent for Assessment for Level of Care (Spanish)  Document Date:  06/20/2018  NEW

Consent for Electroconvulsive Therapy (ECT)  Document Date:  06/20/2018  NEW

Consent for Treatment Form  Document Date:  06/22/2018  NEW

Consent to Release Protected Health Information (PHI) (English)  Document Date:  06/22/2018  NEW

Consent to Release Protected Health Information (PHI) (Spanish)  Document Date:  06/22/2018  NEW

Consent to Sterilization - Attachment A   Document Date:  06/08/2018  NEW

Crisis Response Network Forms  Document Date:  06/11/2018  NEW

Demographic Form  Document Date:  06/22/2018  NEW

DME Prior Authorization Standard Request Form  Document Date:  06/22/2018  NEW

ECT Prior Authorization Request  Document Date:  06/22/2018  NEW 

Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation Document Date:  09/21/2018  NEW

Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation  Document Date:  06/29/2018  NEW

Employment Education Demographic Update Form  Document Date:  06/22/2018  NEW 

EPSDT Standards and Tracking Form  Document Date:  06/11/2018  NEW 

Hysterectomy Consent Form  Document Date:  06/12/2018  NEW 

Interagency PNO Client Transfer Form  Document Date:  06/22/2018  NEW

Level II PASRR Psychiatric Evaluation  Document Date:  06/22/2018  NEW

Member's PCP Change Request Form  Document Date:  06/22/2018  NEW

Missed Appointment Log  Document Date:  08/13/2018  NEW

Move In and Eviction Prevention Service Ticket  Document Date:  06/22/2018  NEW 

Move In and Eviction Prevention Checklist  Document Date:  06/22/2018  NEW 

Move In Assistance Request Process Checklist  Document Date:  06/22/2018  NEW

Move In Assistance Service Ticket  Document Date:  06/22/2018  NEW

Moving Request  Document Date:  06/22/2018  NEW

Network Material Change Transition Grid Template  Document Date:  06/22/2018  NEW

Notice of Adverse Benefit Determination  Document Date:  06/22/2018  NEW   

Notification of persons in need of special assistance  Document Date: 06/11/2018  NEW

Oral Nutritional Supplements - Members 21 Years of Age and Older   Document Date:  06/12/2018  NEW

Outpatient Behavioral Health Single Case Agreement 

PCP Change Request Form  Document Date:  08/24/2018  NEW

Perinatal Referral Form  Document Date:  07/25/2018  NEW

PNO/Agency/Single POC Update

Prior Authorization DME Request Form  Document Date:  06/22/2018  NEW

Prior Authorization: Standard Request Form  Document Date:  03/06/2018  NEW 

Prior Authorization for Family Planning

Prior Authorization for Inpatient Eating Disorder  Document Date:  06/22/2018  NEW

Prior Authorization for Therapy and Home Health Request Form  Document Date:  06/22/2018  NEW

Prior Authorization for Transcranial Magnetic Stimulation   Document Date:  07/27/2018  NEW

Provider Assistance Program Form  Document Date:  06/22/2018  NEW

Psychiatric Security Review Board/GEI Conditional Release Monthly Report Document Date:  06/12/2017 

Psychiatric Rehabilitation Report  Document Date:  06/22/2018  NEW

Psychiatric Visit Information Form  Document Date:  06/22/2018  NEW

Psychological-Neuropsychological Testing Prior Authorization  Document Date:  06/22/2018  NEW 

RBHA and RSA/VR Referral Coordination Form  Document Date:  06/12/2018  NEW 

Re-Certification of Need (RON)  Document Date:  06/25/2018  NEW

Recovia Referral Form  Document Date:  06/25/2018  NEW

Referral for Behavioral Health Residential Facility Services  Document Date:  06/25/2018  NEW

Request for Direct Support or Specialty Provider Services  Document Date:  06/25/2018  NEW 

Resubmission Form  Document Date:  06/20/2018  NEW 

Seclusion and Restraint Individual Reporting Form  Document Date:  06/08/2018  NEW 

Secure Web Portal Registration Form  Document Date:  06/25/2018  NEW

SFTP Connectivity Enrollment  Document Date:  06/25/2018  NEW

Single Case Agreement Rendering Provider Form  Document Date:  06/25/2018  NEW

Single Case Agreement Initial Request Form  Document Date:  06/25/2018  NEW

Single Case Agreement Extension Request Form  Document Date:  06/25/2018  NEW

Skilled Nursing Facility Continued Authorization Request  Document Date:  06/25/2018  NEW

SMI Assessment Packet Checklist  Document Date:  06/26/2018  NEW

Specialist Referral Form  Document Date:  06/26/2018  NEW

Special Treatment Plan for Forced Administration of Medications   Document Date:  06/26/2018  NEW

Supervisory Care Home Monthly Progress Report  Document Date:  06/26/18  NEW

Temporary Extension Hotel Request Form  Document Date:  06/26/2018  NEW

Temporary Hotel Assistance Request  Document Date:  06/26/2018  NEW 

Temporary Hotel Assistance Request Process Checklist  Document Date:  06/26/2018  NEW

Temporary Hotel Assistance Process Checklist  Document Date:  06/26/18  NEW

Therapeutic Residential Service Request for Children and Adolescents  Document Date:  06/26/2018  NEW

Therapy & Home Health Prior Authorization Request Form  Document Date:  06/26/2018  NEW

Transitional Living and Planning Application  Document Date:  08/23/2018  NEW

Twenty-One Day Service Tracking Bi-Monthly Report With Instructions  Document Date:  06/26/2018  NEW

VI-SPDAT

Vocational Profile  Document Date:  06/12/2018  NEW 

Vocational Activity Profile Form -RS Only Document Date: 07/01/18 NEW

Waiver of 3 Day SMI Eligibility Determination (English)  Document Date:  06/26/2018  NEW 

Waiver of 3 Day SMI Eligibility Determination (Spanish)  Document Date:  06/26/2018  NEW