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

Admission to Behavioral Health Hospital or Behavioral Health Inpatient Facility Authorization Criteria

Advanced Directives Resources (English)

Advanced Directives Resources (Spanish)

AETNA Family Planning Remit Format - Check

AETNA Family Planning Remit Format - EFT

AHCCCS Contracted Health Plans Behavioral Health Coordinators  Document Date:  06/02/2017 

Authorization Criteria Adult SMI Behavioral Health Residential Facility 

Authorization Criteria for Behavioral Health Residential Facility Children/Adolescent

Authorization Criteria for Home Care Training for the Home Care Client (HCTC) Children/Adolescent

Behavioral Health Inpatient Facility Continued Stay Authorization Criteria

Behavioral Health Inpatient Facility Admission Authorization Criteria

Collaborative Protocol for Coordination of Care with UnitedHealthcare's Children's Rehabilitative Services (CRS) Programs  Document Date:  04/26/2017 

Collaborative Protocol with Department of Child Safety  Document Date:  04/24/17 

Collaborative Protocol with Department of Economic Security/Division of Developmental Disabilities (DES/DDD) - Child and Adult  Document Date:  06/13/2017 

Collaborative Protocol with Maricopa County Juvenile Probation Department  Document Date:  04/25/2017 

Collaborative Protocol with Phoenix VA Health Care System (PVAHCS)  Document Date:  04/26/2017 

Collaborative Protocols with RSA District I  Document Date:  04/05/2017 

Collaborative Protocol with the Arizona Department of Corrections  Document Date:  04/28/2017 

Continued Behavioral Health Hospital Facility or Behavioral Health Inpatient Facility Authorization Criteria

Coordination of Care Requirements for Inpatient Admission

Crisis Intervention Services Delivered in Emergency Departments

Electroconvulsive Therapy (ECT) Medical Necessity Criteria

ISP Translation Declining Attestation

Mercy Maricopa Remit Format for Check

Mercy Maricopa Remit Format for EFT

Notice to Individuals Receiving Substance Abuse Services (English)

Notice to Individuals Receiving Substance Abuse Services (Spanish)

Peer/Recovery Support Training Requirements

Provider Course Equivalency  Document Date:  06/05/2017 

Provider Deliverables  Document Date:  06/22/2017 

Provider Deliverables Access to Care Template

Provider Deliverables ACT Outcome Report 

Provider Deliverables Peer Support Specialist/Recovery Support Specialist Assignment Roster  Document Date:  05/19/2017 
Provider Deliverables PNO Attestation

Provider Deliverables PNO HEA Report

Provider Deliverables PNO Reports

Provider Deliverables Residential Census Report

Pseudo Provider Numbers

Psychological and Neuropsychological Testing Medical Necessity Criteria 

T/RBHA Acute Health Plan and Provider Coordinator Contact Information  Document Date:  06/02/2017 

Youth Transition to Adulthood Planning Checklist Reference Guide

 

ACT Exit Criteria Screening Tool Form  Document Date:  03/19/2018  NEW

ACT-RBHA RSA/VR Referral Coordination Form  Document Date:  06/11/2017 

ACT Team Residential/Flex Care/CLP with Outside ACT Supports Supplemental Form  Document Date:  02/28/2018  NEW

Referral for Behavioral Health Services

Adult HCTC Application

Advanced Directive Form (English)

Advanced Directive Form (Spanish)

AHCCCS Dental Periodicity Schedule

AM Meeting Checklist

AzAHP Facility Credentialing and Recredentialing Application

AzAHP Organizational Data Form

AzAHP Practitioner Data Form

AzAHP Provider Roster Template 

Bed Bugs Treatment Process Checklist  Document Date:  12/06/2017 

Bed Bugs Treatment Service Ticket  Document Date:  03/22/2017 

Bed Hold or Therapeutic Leave Request for Level I RTC

Biohazard Cleaning Request

Bridge to Permanency Housing Application  Document Date:  08/29/2017 

Business Continuity and Incident Management Plan Checklist

Certification of Need (CON)

Child and Adolescent 45 Day Clinical Review for Continued Prior Residential Facility

Child and Adolescent 60 Day Clinical Review for Continued Stay Prior Authorization of HCTC

Claim Resubmission Form

Community Housing Application  Document Date:  08/31/2017 

Complex Case Review Form Document Date:  03/13/2018  NEW

Consent for Assessment for Level of Care (English)

Consent for Assessment for Level of Care (Spanish)

Consent for Electroconvulsive Therapy (ECT)

Consent for Sterilization (English)

Consent for Sterilization (Spanish)

Consent to Release Protected Health Information (PHI) (English)

Consent to Release Protected Health Information (PHI) (Spanish)

Consent to Treatment Form

Coordination of Care Checklist

Crisis Response Network Forms

Demographic Form

DME Prior Authorization Standard Request Form

ECT Prior Authorization Request  Document Date:  08/08/2017 

Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation

Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation

Employment Education Demographic Update Form  Document Date:  06/12/2017 

Flex Care Supportive Housing Application  Document Date:  10/24/2017 

Hotel Assistance Request Process Checklist  Document Date:  12/6/2017 

Hysterectomy Consent Form

Individual Service Plan - Participation/Recommendation Form  Document Date:  06/11/2017 

Inpatient Eating Disorder Request for Prior Authorization  Document Date:  09/06/2017 

Interagency PNO Client Transfer Form

Level II PASRR Psychiatric Evaluation  Document Date:  06/02/2017 

Member Handbook Receipt

Member's PCP Change Request Form

Monthly Showing Report

Move In and Eviction Prevention Service Ticket  Document Date:  12/6/2017 

Move In and Eviction Prevention Checklist  Document Date:  12/6/2017 

Move In Assistance Request Process Checklist  Document Date:  12/6/2017 

Move In Assistance Service Ticket  Document Date:  04/17/2018  NEW

Moving Request

Network Material Change Transition Grid Template  Document Date:  03/13/2018  NEW

Notice of Adverse Benefit Determination  Document Date:  01/30/2018  NEW 

Notification of Changes to the Network - Required Information

Notification of persons in need of special assistance  Document Date: 03/14/2018  NEW

Outpatient Behavioral Health Single Case Agreement 

PNO/Agency/Single POC Update

Police Mental Health Detention Information Sheet

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

Prior Authorization for Family Planning

Provider Assistance Program Form  Document Date:  04/17/2018  NEW

Provider Staff Add/Change/Delete Form

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

Psychiatric Rehabilitation Report  Document Date:  03/19/2018  NEW

Psychiatric Visit Information Form

Psychological-Neuropsychological Testing Prior Authorization  Document Date:  09/06/2017 

RBHA and RSA/VR Referral Coordination Form  Document Date:  06/12/2017 

Re-Certification of Need (RON)

Recovia Referral Form

Referral for Behavioral Health Residential Facility Services

Request for Direct Support or Specialty Provider Services

Request for Psychological Testing Preauthorization (Revised 12/08/2014)

Scattered Site Housing Application  Document Date:  08/31/2017 

Seclusion and Restraint Individual Reporting Form  Document Date:  12/19/2017 

Seclusion and Restraint Monthly Report

Secure Web Portal Registration Form

SFTP Connectivity Enrollment

Single Case Agreement Rendering Provider Form

Single Case Agreement Initial Request Form

Single Case Agreement Form Instructions

Single Case Agreement Extension Request Form

Skilled Nursing Facility Continued Authorization Request

SMI Assessment Packet Checklist

Specialist Referral Form

Temporary Extension Hotel Request Form  Document Date:  03/15/2018  NEW

Temporary Hotel Assistance Request  Document Date:  12/06/2017 

Therapeutic Residential Service Request for Children and Adolescents

Therapy & Home Health Prior Authorization Request Form

Transitional Living and Planning Application  Document Date:  12/7/2016

Twenty-One Day Service Tracking Bi-Monthly Report With Instructions  Document Date:  02/28/2018  NEW

VI-SPDAT

Vocational Profile  Document Date:  06/20/2017 

Vocational Activity Profile Form -RS Only (English)  Document Date:  06/20/2017 

Vocational Activity Profile Form -RS Only (Spanish)  Document Date:  06/20/2017 

Waiver of 3 Day SMI Eligibility Determination (English)

Waiver of 3 Day SMI Eligibility Determination (Spanish)