Providers

Forms

Supplemental Code Set – Dental

Medical Services Prior Authorization Form

Pharmacy Medication Prior Authorization Form

EFT/ERA Request Form

Medicare Prescription Drug Coverage and Your Rights

Waiver of Liability Statement

Maternal Health Risk Assessment

Case Management Referral Form

Fraud, Waste and Abuse Referral form

Request for Participation – AzAHP Practitioner Data Form

Request for Participation – AzAHP Organizational Data Form

AzAHP Facility Application

Prior Authorization and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities

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