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Provider Forms 

You'll find all forms we currently use in the following list. Check back frequently to see what's changed or updated.
 

 

CRS Medical/Behavioral Health Materials

CRS Master Diagnosis List (PDF 3.96 MB) 
CRS Program Coverage Types - One Sheet (PDF 141.62 KB) 
CRS Transportation Flyer (PDF 100.58 KB)  

CRS Medication Prior Authorization Request Form (PDF 21.26 KB) - This form needs to be completed by the requesting provider and faxed to UnitedHealthcare Community Plan.

CRS Prior Services Request Form (PDF 366.14 KB) - This form needs to be completed by the CRS MSIC or specialist and faxed to UnitedHealthcare Community Plan CRS at 1-888-899-1499 or call us at 1-866-604-3267.

 

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

Adaptive Aids (PDF 16.19 KB)
Beds - Partially (Open Top) or Completely Enclosed Beds (PDF 16.84 KB)
Car Seats (PDF 13.76 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

Agency Roster Update Form (PDF 160.73 KB) - Use this form to ensure proper maintenance of your independently licensed clinician roster. Complete and submit this form as staffing changes occur. Updated 3.29.2018

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

American College of Obstetricians and Gynocologists (ACOG) - ACOG members can sign in to access the required forms.

American College of Obsterticians and Gynocologists (ACOG) Antepartum Record Form (PDF 638.7 KB)

AzAHP Facility Credentialing & Recredentialing Application Form (PDF 337.24 KB) - 6.18.2018 

AzAHP Organizational Data Form (PDF 282.81 KB) - Updated 6.18.2018

AzAHP Practitioner Data Form (PDF 362.99 KB) - Updated 6.18.2018 

Care Provider Referral Form (PDF 59.83 KB) - Use this form to refer patients to contracted physicians and providers.

Durable Medical Equipment (DME) Prosthetics Orthotics and Supplies Request Form (PDF 67.88 KB)

EPSDT Standards and Tracking Forms

EPSDT Periodicity Schedule and Information (PDF 51.66 KB) 

Long-Acting Opiates Prior Authorization Form (PDF 534.99 KB)

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

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

Newborn Notification Form (PDF 102.38 KB)

Primary Care Provider Change Request Form and Instructions (PDF 86.27 KB) - 7.03.2018 

Prior Authorization Fax Request Form (PDF 233.99 KB)

Prior Authorization Fax Form for Prosthetic and Orthotic Service Requests (PDF 79.64 KB) - Use this fax form to submit Prior Authorization requests for Prosthetic/Orthotic items and supplies.

Provider Clinical Tools

Report Suspected Fraud or Abuse Form (PDF 113.06 KB)

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

Wheelchair Seating and Positioning Evaluation Form (PDF 240.65 KB) - Use this form for a patient Wheelchair Seating and Positioning Evaluation.