• Forms

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.

  1. American Dental Association Dental Claim Form
  2. Appointment of Representative Form
  3. Attachment C
  4. Behavioral Health Services Referral Form
  5. Certificate of Medical Necessity for Commercial Oral Nutritional Supplements (ALTCS Members 21 years of age and older)
  6. Certificate of Medical Necessity for Commercial Oral Nutritional Supplements (EPDST Members)
  7. CMS 1500
  8. Consent for Sterilization Form
  9. Dental Prior Authorization Request Form
  10. Durable Medical Equipment Medial Decision Record (DMEMDRR)
  11. Durable Medical Equipment, Orthotics and Prosthetics Prior Authorization Request Form
  12. Electronic Funds Transfer
  13. Electronic Remit Request Form
  14. EPSDT Standards and Tracking Forms
  15. EPSDT Supply Order Form
  16. GYN Prior Authorization Form
  17. Initial Request Form - Ancillary/Facility
  18. Initial Request Form - Professional
  19. LTC Counseling Authorization Renewal Form
  20. Mercy Care Plan Remit Format for Check Form
  21. Mercy Care Plan Remit Format for EFT Form
  22. Mercy Care Referral Form (MCP Referral Form)
  23. Non Formulary Request (MCP Non Formulary Request)
  24. OB Prior Authorization Form
  25. Primary Care Provider ADHD Monitoring Form (MCPPCPADHD)
  26. Prior Authorization Request Form
  27. Provider Assistance Program
  28. Provider Contact Form
  29. Provider Notice Of Change Form
  30. RBHA Referral Form Instructions Maricopa County Only
  31. RBHA Referral Form Maricopa County Only
  32. RBHA Referral Form Non Maricopa Counties Only
  33. Resubmission Form
  34. SA FPS Remit Format for Check Form
  35. SA FPS Remit Format for EFT Form
  36. Schaller Anderson Family Planning Prior Authorization Form
  37. Speciality Medication Authorization Form
  38. Synagis Authorization Form
  39. Therapy and Home Health Prior Authorization Form
  40. UB-04 CMS 1450

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.