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.

• 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.
Not registered yet? Visit Availity’s Register and Get Started page.
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
• 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
  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) 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.
  • 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).