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

1500 (02-12) Form Completion Instructions

834 Transaction Data Requirements

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  NEW

Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation

Arizona PATH Program - Administrators Contact List

ARS 12-136 Flow Chart "Domestication" or Recognition of Tribal Court Order Process

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

Case Management Assignment Criteria

Citizenship/Lawful Presence Verification Process through Health-e-Arizona Plus

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

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

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

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

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

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

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

Community Service Agency Criminal History Affidavit

Community Service Agency Daily Clinical Record Documentation Form

Community Service Agency Self Declaration of Criminal History

Community Service Agency Title XIX Certificate

Community Service Agency Title XIX Certification - Amendment

Community Service Agency Title XIX Certification - Direct Service Staff/Contractor Reference Form

Community Service Agency Title XIX Certification - Initial Application

Community Service Agency Title XIX Certification - Intent to Contract Form

Community Service Agency Title XIX Certification - Notice of Deficiency

Community Service Agency Title XIX Certification - Renewal Application

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

DES/DCYF Child Welfare Timeframes

Documents Accepted by AHCCCS to Verify Citizenship and Identity

Electroconvulsive Therapy (ECT) Medical Necessity Criteria

ISP Translation Declining Attestation

Mercy Maricopa Remit Format for Check

Mercy Maricopa Remit Format for EFT

Non-Citizen/Lawful Presence Verification Documents

Notice to Individuals Receiving Substance Abuse Services (English)

Notice to Individuals Receiving Substance Abuse Services (Spanish)

Overview of the Arizona Families F.I.R.S.T (AFF) Program

Parent/Family Support Suggested Curriculum Development References

PASRR Screening Document Level I

Peer/Recovery Support Training Requirements

Persons who are Exempt from Verification of Citizenship during the Prescreening and Application Process

Provider Course Equivalency  Document Date:  06/05/2017  NEW

Provider Deliverables  Document Date:  06/22/2017  NEW

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 (Revised 12/08/2014)

Requirements to Verify Citizenship for Non-AHCCCS Eligible Individuals

Seclusion and Restraint Emergency Safety Response Reporting Requirements 

Serious Mental Illness (SMI) Qualifying Diagnoses

Service Plan Rights Acknowledgement Template

SMI and SED Qualifying Diagnoses Table

Submitting Claims and Encounters

Substance Abuse Disorders Qualifying Diagnoses Table

Substance Use/Psychiatric Symptomatology Table

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

T/RBHA Codes for Docket Numbers

Timeframes for Data Collection and Submission

TPL and Coordination of Benefits - Non-Title XIX/XXI Eligible Persons Determined to have a SMI

TPL and Coordination of Benefits - Title XIX/XXI Eligible Persons

Youth Transition to Adulthood Planning Checklist Reference Guide

UB-04 (CMS 1450) Form Completion Instructions

1500 (02-12) Form

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

ACT Team Residential/CLP with Supports Supplemental Form

Referral for Behavioral Health Services

Adult HCTC Application

Advanced Directive Form (English)

Advanced Directive Form (Spanish)

Affidavit

AHCCCS Dental Periodicity Schedule

AHCCCS Notification to Waive Medicare Part D Copayments

AM Meeting Checklist

Appeal or SMI Grievance Form (English)

Appeal or SMI Grievance Form (Spanish)

Application for Emergency Admission for Evaluation

Application for Involuntary Evaluation

Application for Voluntary Evaluation (English)

Application for Voluntary Evaluation (Spanish)

Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation Users Guide

AzAHP Facility Credentialing and Recredentialing Application

AzAHP Organizational Data Form

AzAHP Practitioner Data Form

AzAHP Provider Roster Excel Spreadsheet

Bed Bugs Treatment Process Checklist  Document Date:  03/22/2017 

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

Bed Hold or Therapeutic Leave Request for Level I RTC

Behavioral Health Technician Case Supervision Report

Biohazard Cleaning Request

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

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

Communication Document

Community Housing Application  Document Date:  08/31/2017  NEW

Community Service Agency/HCTC Provider Daily Clinical Record Documentation Form

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

Decline to Participate in the Screening and/or Referral Process for AHCCCS (Title XIX/XXI) Health Insurance or Medicare, including Part D Plan Enrollment (English )

Decline to Participate in the Screening and/or Referral Process for AHCCCS (Title XIX/XXI) Health Insurance or Medicare, including Part D Plan Enrollment (Spanish)

Demographic Form

Dental Prior Authorization Form

DME Prior Authorization Standard Request Form

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

Electronic Funds Transfer (EFT) Enrollment/Change/Cancellation

Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation

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

EPSDT Periodicity Schedule

EPSDT Certificate of Medical Necessity for Oral Nutritional Supplements

EPSDT Standards and Tracking Forms

EPSDT Supply Order Form

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

Hotel Assistance Request Process Checklist  Document Date:  03/22/2017  NEW

Hysterectomy Consent Form

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

Informed Consent for Psychotropic Medication Treatment (English)

Informed Consent for Psychotropic Medication Treatment (Spanish)

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

Interagency PNO Client Transfer Form

Inter-RBHA Coordination of Services

Inter-RBHA Transfer Request 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 Assistance Service Ticket  Document Date:  03/21/2017  NEW

Moving Assistance Request Process Checklist  Document Date:  03/21/2017  NEW

Moving Request

Non-Formulary Medications Prior Authorization Form

Notice of Action  Document Date:  06/11/2017  NEW 

Notice of Decision and Right to Appeal (for Individuals with a Serious Mental Illness) (English)

Notice of Decision and Right to Appeal (for Individuals with a Serious Mental Illness) (Spanish)

Notice of Discrimination Prohibited

Notice of Extension of Timeframe for Service Authorization Decision Regarding Title XXI/XIX Services (English)

Notice of Extension of Timeframe for Service Authorization Decision Regarding Title XXI/XIX Services (Spanish)

Notice of Legal Rights for Persons with Serious Mental Illness (English)

Notice of Legal Rights for Persons with Serious Mental Illness (Spanish)

Notification of Changes to the Network - Required Information

Notification of persons in need of special assistance  Document Date: 03/01/2017 

Out of State Placement Form

Outpatient Behavioral Health Single Case Agreement 

Petition for Court-Ordered Evaluation

Petition for Court-Ordered Treatment Gravely Disabled Person

PNO/Agency/Single POC Update

Police Mental Health Detention Information Sheet

Pre-Admission Screening and Resident Review Invoice Document Date: 06/02/2017  NEW

Pre-Petition Screening Report

Prior Authorization Standard Request Form  Document Date:  06/19/2017  NEW

Prior Authorization for Family Planning

Provider Assistance Program Form

Provider Staff Add/Change/Delete Form

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

Psychiatric Rehabilitation Report  Document Date:  06/12/2017  NEW

Psychiatric Visit Information Form

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

Quarterly PATH Report

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

Re-Certification of Need (RON)

Recipient Transition from RBHA to PCP Log

Recovia Referral Form

Referral for Behavioral Health Residential Facility Services

Request for Direct Support or Specialty Provider Services

Request for Information from PCP or Medicare Plan/Provider

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

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

Seclusion and Restraint Monthly Report

Seclusion and Restraint Reporting Level I Programs

Secure Web Portal Registration Form

Serious Mental Illness Determination

Serious Mental Illness Determination Verification

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

Substance Abuse Prevention Program and Evaluation Consent (English)

Substance Abuse Prevention Program and Evaluation Consent (Spanish)

Supervision of Clinical Liaisons - Attestation of Competencies

Temporary Extension Hotel Request  Document Date:  03/22/2017 

Therapeutic Residential Service Request for Children and Adolescents

Therapy & Home Health Prior Authorization Request Form

Tracking of Low Income Subsidy Status

Tracking of Medicare Part D Enrollment

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

VI-SPDAT

Vocational Profile  Document Date:  06/20/2017  NEW

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

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

Waiver of 3 Day SMI Eligibility Determination (English)

Waiver of 3 Day SMI Eligibility Determination (Spanish)