Forms For Providers
Recertificate of Need (RON) 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
Care Management Referral Form
CRS Application – English
CRS Application – Spanish
Formulary Addition Request Form
Fraud Waste & Abuse Referral Form
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
SHOUT Protocol Referral Form FAQs
SHOUT Referral Form
Enrollment Transition Information (ETI) Form
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s preventive health benefit for AHCCCS members from birth through age 20. EPSDT services—also known as well‑child visits—support the early identification and treatment of physical, developmental, behavioral, and oral health conditions.
Providers must follow AHCCCS EPSDT requirements and document visits using the AHCCCS EPSDT Clinical Sample Templates or an EHR that captures all required elements.
Quick access: AHCCCS EPSDT Periodicity Schedule (ages & required components) AMPM 430 - Attachment A
Submitting EPSDT Forms
After each EPSDT/well‑child visit, providers must:
- Complete the age‑appropriate AHCCCS EPSDT form (or approved EHR equivalent)
- Maintain documentation in the member’s medical record
- Submit completed EPSDT documentation to Blue Cross Blue Shield of Arizona Health Choice using approved submission methods—do not send EPSDT forms to AHCCCS (submissions should go to the member’s health plan)
Preferred submission (for faster processing):
- Email: HCHEPSDTCHEC@azblue.com
- Fax: (480) 760‑4716
Blue Cross Blue Shield of Arizona Health Choice
Attn: EPSDT Team
8220 N 23rd Ave.
Phoenix, AZ 85021
Timeliness: Please submit forms as often as possible—at least monthly. Timely submissions support care coordination, referral follow‑up, and quality reporting required by AHCCCS.
EPSDT Tracking Forms
- EPSDT Tracking Form 3-5 Days Old
- EPSDT Tracking Form 1 Month Old
- EPSDT Tracking Form 2 Months Old
- EPSDT Tracking Form 4 Months Old
- EPSDT Tracking Form 6 Months Old
- EPSDT Tracking Form 9 Months Old
- EPSDT Tracking Form 12 Months Old
- EPSDT Tracking Form 15 Months Old
- EPSDT Tracking Form 18 Months Old
- EPSDT Tracking Form 24 Months Old
- EPSDT Tracking Form 30 Months Old
- EPSDT Tracking Form 3 Years Old
- EPSDT Tracking Form 4 Years Old
- EPSDT Tracking Form 5 Years Old
- EPSDT Tracking Form 6 Years Old
- EPSDT Tracking Form 7-8 Years Old
- EPSDT Tracking Form 9-12 Years Old
- EPSDT Tracking Form 13-17 Years Old
- EPSDT Tracking Form 18-21 Years Old