Skip to Main Content

PROVIDER MANUAL FORMS and ATTACHMENTS

Please call Customer Service at 1-866-796-0542 for a copy of any Forms or Attachments listed below.

2.2       Maternity Services

  •   2.3.2 Notification of Pregnancy (NOP)

12.7     General and Informed Consent to Treatment

  •  Provider Manual Form 3.7.1 General Consent to Treatment
  •  Provider Manual Form 3.7.1 General Consent to Treatment - Spanish

12.13   Out-of-State Placements for Children and Young Adults

  • Provider Manual Form 3.13.1 Out-of-State Placement, Initial Notice and 30 day Update

13.1     Transition of Persons

  • Provider Manual Form 4.1.1 Inter-Agency Transfer & Transition Checklist

13.2     Inter-RBHA Coordination of Care

  • Provider Manual Form 4.2.1 AzCH Inter T/RBHA Transfer and Coordination of Services Request Form
  • Provider Manual Form 4.2.3 AZ Complete Health Authorization for Release-Generic

10.9     Seclusion and Restraint Reporting

  • Provider Manual Form 10.10.1 Seclusion and Restraint Reporting

4.1       Securing Services and Prior Authorization/Retrospective Authorization

  • Provider Manual Form 10.1.1 Certification of Need (CON)
  • Provider Manual Form 10.1.2 Recertification of Need (RON)
  • Provider Manual Form 10.1.3 Notice of Admission to ALL LEVELS OF CARE
  • Provider Manual Form 10.1.6 Concurrent Review
  • Provider Manual Form 10.1.8 Pre-Authorization Out-of-Home
  • Provider Manual Form 10.1.12 Outpatient Medicaid Prior Authorization Fax Form
  • Provider Manual Form 10.1.13 Inpatient Medicaid Prior Authorization Fax Form
  • Provider Manual Form 10.1.14 Intensive Staff - CCR
  • Provider Manual Form 10.1.15 Out-of-Network Request
  • Provider Manual Form 10.1.16 Notice of Temporary Placement MASTER
  • Provider Manual Form 10.1.17 Notice of Transfer Out of Home Facilities MASTER

1.3  Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers

  • Provider Manual Form 13.3.1 Request for Information from PCP or Medicare Provider
  • Provider Manual Form 13.3.2 PCP Communications Document

9.3   Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits

  • Provider Manual Attachment 12.2.1, Documents Accepted by AHCCCS to Verify Citizenship and Identity
  • Provider Manual Attachment 12.2.2, Citizenship/Lawful Presence Verification Process Through Health-e-Arizona PLUS
  • Provider Manual Attachment 12.2.3, Persons Who Are Exempt from Verification of Citizenship During the Prescreening and Application Process
  • Provider Manual Attachment 12.2.4, Non-Citizen/Lawful Presence Verification Documents

10.9 Seclusion and Restraint Reporting

  • Provider Manual Attachment 9.9.1 Seclusion and Restraint Reporting Form

12.6 Assessment and Service Planning

  • Provider Manual Attachment 3.5.1 Service Plan Rights Acknowledgement Template
  • Provider Manual Attachment 3.5.8 Functional Behavioral Assessment Guidance Document

12.8 Psychotropic Medication: Prescribing and Monitoring

  • Provider Manual Attachment 3.8.5 Monitoring Parameters for Psychotropic Medications