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

834 Transaction Data Requirements
ADHS/DBHS Notice of SMI Grievance and Appeal Procedure  (English)
ADHS/DBHS Notice of SMI Grievance and Appeal Procedure  (Spanish)
ADHS/DBHS Org Culture Assessment 2014
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 NEW
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
IAD QOC Reporting Training
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  NEW
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
Where to Submit Claims and Encounters
Youth Transition to Adulthood Planning Checklist Reference Guide

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

ACT Team Residential/CLP with Supports Supplemental Form

ADHS/DBHS Appeal or SMI Grievance Form (English)

ADHS/DBHS Appeal or SMI Grievance Form (Spanish)

ADHS/DBHS 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

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

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

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

Bed Hold or Therapeutic Leave Request for Level I RTC

Behavioral Health Technician Case Supervision Report

Biohazard Cleaning Request

Bridge to Permanency Housing Application 

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 Revised

Communication Document

Community Housing Application

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 Treatment Form

Coordination of Care Checklist

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:  03/28/2017  NEW

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

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

Hysterectomy Consent Form

Incident, Accident, Death Reporting 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)

Interagency PNO Client Transfer Form

Inter-RBHA Coordination of Services

Inter-T/RBHA Transfer Request Form

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

Member Handbook Receipt

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

Network Material Change Transition Grid

Non-Formulary Medications Prior Authorization Form

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

Notice of Extension

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

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

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

Referral for Behavioral Health Residential Facility Services NEW

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 

Seclusion and Restraint Monthly Report

Seclusion and Restraint Reporting Level I Programs

Serious Mental Illness Determination

Serious Mental Illness Determination Verification

Single Case Agreement Rendering Provider Form

Single Case Agreement Initial Request Form

Single Case Agreement Form Instructions

Single Case Agreement Extension Request Form

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)