Last Updated on June 27, 2022
Health Choice Arizona Forms For Providers
Request for Participation
Request for Participation – AzAHP Practitioner Data FormRequest for Participation – AzAHP Organizational Data Form
AzAHP Facility Application
Provider Roster
Prior Authorization Forms
Synagis Authorization FormDental Specialty Request Form
Medical Services Prior Authorization Form
Pharmacy Services Prior Authorization Form
BHIF, BHRF, TFC Prior Authorization and Continued Stay Request Form
PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities
Notification of Admission, Transfer and Discharge for Out of Home Placements
Northern AZ ED Reporting
Claims Forms
CMS HCFA-1500 Claim FormAHCCCS FFS Provider Billing Assistance – 1500 Claim Form
UB-04 Claim Form
AHCCCS FFS Provider Billing Assistance – UB Claim Form
Performance Toolkits
Physician’s Coding ToolkitOther Forms
AzEIP AHCCCS Member Service Request FormAHCCCS EPSDT Periodicity Schedule
Care Management Referral Form
CRS Application – English
CRS Application – Spanish
Formulary Addition Request Form
Fraud Waste & Abuse Referral Form
Transportation Referral Form
EPSDT Tracking Form Order Sheet
EPSDT Medical Necessity for Nutritional Supplements
Missed Dental Appointment Log
Missed Medical Appointment Log
Maternal Risk Assessment
Newborn Reporting Form
Pediatric NICU Case Management Referral Form
Federal Sterilization Consent Form
Hysterectomy Consent Form – English
Hysterectomy Consent Form – Spanish
SHOUT Protocol Referral Form FAQs
SHOUT Referral Form
Enrollment Transition Information (ETI) Form
SMI Verification Form
RBHA Change Form (RCF)
Health Risk Assessments
Adult HRA -ENGAdult HRA – SPA
Pediatric HRA – ENG
Pediatric HRA – SPA
