Forms
- Member Appeals Forms
- AZ Blue Member Appeal/Grievance Packet – for most commercial group plans and grandfathered and grandmothered individual/family plans
- ACA Member Appeal/Grievance Packet – for ACA individual/family plans
- Self-Funded Group Appeal/Grievance Packet - for some self-funded employer groups, except those that have their own customized appeal packets, including:
- State of Arizona (group 30855; member ID prefixes SYD and S3Z)
- Teamsters (groups 31843 and 31844; member ID prefix TYW)
- U-Haul (group 026229; member ID prefix UHL) – see the member benefit book
- Appeal and Grievance Request Form
- Provider Certification Form for Expedited Appeal
- Authorized Representative Designation Form
Need help? Call 602-544-4938 or 1-866-595-5998.
Medicare Advantage Member Appeal/Grievance Forms- CMS Appointment of Representative form (CMS-1696): Access from the CMS Forms List. (Opens in a new tab)
- Corrected Claim Form (PDF)
- Non-Contracted Provider (PDF)
- Notice of Excess Payment (PDF)
EFT (Electronic Funds Transfer)
We’ve moved our EFT form to the Availity Essentials provider portal. (Opens in a new tab)
Not registered yet? Visit Availity’s Register and Get Started page. (Opens in a new tab)
EFT Form - Provider FAQs (PDF)
EFT Enrollment and Changes – Instructions (PDF)ERA (Electronic Remittance Advice)
ERA Enrollment/Change Form (PDF)
ERA Enrollment/Change - Instructions (PDF)Use the following forms to request contracting/credentialing and to add a tax ID to your contract. To update other provider information, please use the Provider Information Change Form.
- Dental Contract-Credentialing Form – Requires a CAQH Dental profile and number (Opens in a new tab)
- Facility/Ancillary Contract-Credentialing Form – Also use this form to add a tax ID (PDF)
- Medical Professional-Individual Contract-Credentialing Form – Requires a CAQH profile and number (Opens in a new tab)
Also use this form to add a tax ID to your contract
Notes:
- If you are a PT/ST/OT professional and are part of a group, your group must have a group contract on file with us before we can complete your credentialing.
- Chiropractors must apply through American Specialty Health (ASH) (Opens in a new tab) at 1-888-511-2743.
- Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum.
- TriWest Health Alliance Network (for Veterans)
- To request a contract for the TriWest Healthcare Alliance Network, please visit the TriWest contracting page. (Opens in a new tab)
- If you already have a contract with TriWest and would like to be credentialed or update your contract, please complete the above facility or professional forms.
- Termination Form (for termination of provider contract or affiliation with tax ID)
- No Surprises Act Information and Forms (Resource Page)
- Prior Authorization Request Forms (Resource Page)
- Content restricted by user role or network status (or both).
- Provider Relations Contact Lookup (Online)
- Termination Form (PDF)
To bill members with AZ Blue commercial plans for services considered investigational or not medically necessary, obtain informed consent and a written waiver of billing restrictions, such as this form: Waiver of Billing Restrictions Form - commercial plans only (PDF)
Note: Use this form for members with AZ Blue commercial plans only. This form is not applicable for commercial plans administered by a third-party administrator (TPA) or another Blue Plan (BlueCard out-of-area plans), and Medicare Advantage plans (CMS requires a pre-service determination and notice of denial).