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   Providers > Forms


Forms


Download Forms:
   
Access to Behavioral Health Care for PCPs
Behavioral Health Services Referral Form

Claim Dispute Form

Credentialing/ Recredentialing Application

Dental Treatment Authorization Request
EFT Authorization Form
EPSDT Order Form
EPSDT Tracking Forms  
Facility/Ancillary Provider Data Form
Organizational Credentialing Application
No Show Log
Pharmacy Authorization Form
Practitioner Data Form
Pregnancy Risk Assessment Form
Provider Listing Correction Request Form
RSV Prophylaxis Eligibility Assessment Form
Treatment Authorization Form
   

 

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Please note that all materials found on this website are also available in hard copy by contacting Member Services at 602-778-1800 or
1-866-560-4042 or by e-mailing us through the link located in this website.

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