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.

• CMS Appointment of Representative form (CMS-1696): Access from the CMS Forms List. (Opens in a new tab)

• Provider Grievance Form
• No Surprises Act (NSA) forms and information

• Care Management Referral Form (PDF)

• Corrected Claim Form (PDF)
• Non-Contracted Provider (PDF)
• Notice of Excess Payment (PDF)

• Consultant or Billing Company Policy and Attestation Form (PDF)

• AZ Blue Member COB Information Form (PDF)
• BlueCard (Out-of-Area) Member COB Information Form (PDF)
• Medicare Advantage Member COB Information Form (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)

• Mental Health Parity Disclosure Request Form (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)

• Non-Contracted Provider Information Form (PDF)

• No Surprises Act Information and Forms (Resource Page)

• PCMH Program Interest Form (PDF)

• Prior Authorization Request Forms (Resource Page)

Dental Providers-Information Change Form (PDF)

 Medical Providers-Information Change Form (Online)

Non-Contracted Providers-Information Change 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).