UnitedHealthcare Community Plan
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You'll find all forms we currently use in the following list.

We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.

CRS Behavioral Health

Agency Roster Update Form (PDF 47.49 KB)
Clinician Add/Change Application Form (PDF 154.02 KB)
Specialty Attestation Form (PDF 604.59 KB)

CRS Medical/Behavioral Health Materials 

CRS Master Diagnosis List (PDF 3.71 MB) 
CRS Program Coverage Types - One Sheet (PDF 141.62 KB) 
CRS Crisis Network Update (PDF 65.27 KB) 
CRS Transportation Flyer (PDF 100.58 KB)  
CRS Provider Forum Presentation (PDF 2.6 MB)

CRS Medication Prior Authorization Request Form (PDF 21.26 KB) This form is to completed by the requesting provider and faxed to UnitedHealthcare Community Plan at 1-866-604-3267.

CRS - Provider Service Requisition Form (PDF 67.08 KB) This form is to be completed by the CRS MSIC or specialist and faxed to UnitedHealthcare Community Plan CRS at 1-888-899-1499 or CALL 1-866-604-3267

Division of Developmental Disabilities, Prior Authorization Criteria (Select Services)

Adaptive Aids (PDF 16.19 KB)
Car Seats (PDF 13.76 KB)
Partially (Open Top) or Completely Enclosed Beds (PDF 16.84 KB)
Gait Trainers (PDF 16.97 KB)
High Frequency Chest Wall Oscillation Vests (PDF 18.31 KB)
Hospice Admission Protocol (PDF 20.2 KB)
Nutritional Supplements (PDF 18.62 KB)
Sterilization Prior Authorization Criteria (PDF 22.79 KB)
Vagus Nerve Stimulator (PDF 14.88 KB)

Additional Forms

AHCCCS/Medicaid, DD, Dual Complete Prior Authorization Fax Form (PDF 74.89 KB)

Vendor Quick Reference Grid for All Lines of Business (PDF 878.37 KB)

Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 145.65 KB)
ACOG Antepartum Record (PDF 638.7 KB)
AzAHP Practitioner Data Form (PDF 750.51 KB)  - July 17, 2013
AzAHP Organizational Data Form (PDF 716.39 KB) - July 17, 2013
Report Suspected Fraud or Abuse Form (PDF 113.06 KB)
Newborn Notification Form (PDF 102.38 KB)
Provider Demographic Update Fax Form (PDF 173.12 KB)
EPSDT Standards and Tracking forms
Botulinum Toxins Prior Authorization Form (PDF 606.1 KB) 
Immune Globulin Prior Authorization Form (PDF 554.28 KB) 
Makena Prior Authorization Form  (PDF 484.57 KB)
Claim Reconsideration Request Form (PDF 776.02 KB)

The "Physician and provider demographic change submission form" (#M44539-A or M44539-B) on the CD version of the Welcome Kit includes an outdated fax number. The corrected form is here (PDF 294.5 KB).

Prior Authorization Fax Form for Prosthetic and Orthotic Service Requests (PDF 79.64 KB) - 
This fax form has been developed to streamline the Prior Auth request process for Prosthetic/Orthotic items and supplies.

Long Term Care Prior Authorization FAX Request Form (PDF 99.55 KB)

Long Term Care Therapy Prior Authorization Request (PDF 81.39 KB)

EPSDT Periodicity Schedule (PDF 9.47 KB) Well-child visits for members from birth to 20 years of age must include services as indicated in the attached EPSDT Periodicity Schedule.

Missed Member Appointments (Fax Form) (PDF 104.46 KB) UnitedHealthcare Community Plan can help your office minimize member missed appointments. Please notify us within five days by faxing back this form when our members have missed a scheduled appointment, or have given less than 24 hours notice to cancel an appointment.

Pharmacy Prior Authorization form (PDF 53.02 KB) Required form for prescriptions or for medications not on the Medicare Part D Drug List. Phone: (800)305-0023 | Fax: (877)265-4976

Physician Referral Form (PDF 38.26 KB) Use this form to refer patients to contracted physicians/providers.

Provider Clinical Tools

Regional Behavioral Health Authority (RBHA) Referral Form (Policy Form 103.1)

Return Overpayment - by check (ZIP 684.64 KB) In order for UnitedHealthcare Community Plan to recover an overpayment from you by check, UnitedHealthcare Community Plan requires your authorization. Use this packet to learn how to return an overpayment by check.

New Sterilization Form Available (PDF 85.85 KB)
New Sterilization form is available on the AHCCCS website – AMPM Chapter 420, Exhibit 420-1

Return Overpayment - through an adjustment request (ZIP 684.73 KB) In order for UnitedHealthcare Community Plan to recover an overpayment through adjusting future payments, UnitedHealthcare Community Plan requires your authorization. Use this packet to learn how to return an overpayment through an adjustment request.

Waiver of Liability Statement (PDF 13.77 KB) Required form to waive right to collect payment from enrollees.

Wheelchair Seating and Positioning Evaluation Form (PDF 240.65 KB) To provide providers a form for Wheelchair Seating and Positioning Evaluation.