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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.

Vendor Quick Reference Grid for All Lines of Business (PDF 900.14 KB)


CRS Behavioral Health

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 3.96 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 at 1-866-604-3267.

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)

ACOG Antepartum Record (PDF 638.7 KB)

AzAHP Facility Credentialing & Recredentialing Application Form (PDF 146.96 KB) - 2.14.2018 

AzAHP Organizational Data Form (PDF 127.1 KB) - Updated 2.14.2018

AzAHP Practitioner Data Form (PDF 143.07 KB) - Updated 2.14.2018 

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

Claim Reconsideration Request Form (PDF 776.02 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 EPSDT Periodicity Schedule.

EPSDT Standards and Tracking Forms

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)

Missed Member Appointments (Fax Form) (PDF 104.46 KB) - We 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.

Newborn Notification Form (PDF 102.38 KB)

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

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 Demographic Update Fax Form (PDF 173.12 KB)

Provider Clinical Tools

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

Report Suspected Fraud or Abuse Form (PDF 113.06 KB)

Return Overpayment by Check (ZIP 684.64 KB) - We require your authorization in order for UnitedHealthcare Community Plan to recover an overpayment from you by check. Use this form to learn how to return an overpayment by check.

Return Overpayment through an Adjustment Request (ZIP 684.73 KB) - We require your authorization in order for UnitedHealthcare Community Plan to recover an overpayment through adjusting future payments. Use this form to learn how to return an overpayment through an adjustment request.

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

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) - Use this form for a patient Wheelchair Seating and Positioning Evaluation.