Provider tools

Forms

Click on the link to the forms you need to access. Download a copy and follow the instructions on the form.

Network Management Forms

AZAHP Facility Application

AZAHP Facility Org Data Form 

AZAHP Practitioner Form 

W9 Tax Form

 

Utilization Management Prior Authorization

2018 NIA Cardiac HiTech Sleep Matrix

2018 NIA IPM and Spine Surgery Matrix

*New* 2019 NIA Cardiac HiTech Sleep Matrix

*New* 2019 NIA IPM and Spine Surgery Matrix

Prior Authorization List 

Prior Authorization Code List

 

Utilization Management Forms

Prior Authorization Form

ABA Prior Authorization Form

Synagis Prior Authorization Request Form

 

Pharmacy Forms

Prescription Drug Prior Authorization

 

Other Forms

Authorization to Use and Disclose (AUD) Form

General Consent Form

Hysterectomy Consent Form

Newborn Notification Fax Form

Notification of Pregnancy Form

Out of State Placement Form

Seclusion and Restraint Reporting Form

Pregnancy Termination Form Exhibit 410-5*

Consent to Sterilize Form - 420A*

*Form must be submitted via email on a secure server and password protected to the MCH/EPSDT Program Manager at MCCofAZMissedAppointments@magellanhealth.com.

 

EPSDT Tracking Forms

EPSDT Tracking Forms Cover Sheet and Instructions 

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 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