AZBlue Health Choice Forms For Providers
- Synagis Authorization Form
Dental Specialty Request Form
Medical Services and Behavioral Health Prior Authorization Form
Pharmacy Services Prior Authorization Form
BHIF, BHRF, TFC, and SUD BHRF Prior Authorization and Continued Stay Request Form
PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities
Northern AZ ED Reporting - AzEIP AHCCCS Member Service Request Form
Care Management Referral Form
CRS Application – English
CRS Application – Spanish
Formulary Addition Request Form
Fraud Waste & Abuse Referral Form
Transportation Referral Form
EPSDT Clinical Sample Template
EPSDT Medical Necessity for Nutritional Supplements
Missed Medical Appointment Log
Missed Dental Appointment Log
Maternal Risk Assessment
Newborn Reporting Form
Pediatric NICU Case Management Referral Form
Federal Sterilization Consent Form
Hysterectomy Consent Form – English
Hysterectomy Consent Form – Spanish
SHOUT Protocol Referral Form FAQs
SHOUT Referral Form
Enrollment Transition Information (ETI) Form
Call Us
CRISIS HELP: 1-844-534-HOPE (4673) or Text 4HOPE (44673)
24/7 Nurse Advice Line: 1-888-267-9037
Call Us: 1-800-322-8670 (TTY:711)