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Forms
Whether you need to file a claim, inform us of a change of address or request prior authorization for a treatment, filling out the necessary forms will help us respond to your needs quickly and efficiently. Just click on the appropriate form name below to get started.
Durable Medical Equipment, Orthotics and Prosthetics Prior Authorization Request Form
Electronic Funds Transfer (EFT) Form
Initial Request Form Ancillary
Initial Request Form Professional
LTC Counseling Authorization Renewal Form
Prior Authorization Request Form
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Supporting Information
- Regulatory
- Medical Policies
- Facilities
4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Arizona 85040
Member Services
7 a.m. to 6 p.m. Monday-Friday
602-263-3000,
Toll-free 1-800-624-3879
(TTY/TDD)
Toll-free: 1-866-602-1982
If you or a family member has a medical emergency, dial 911.