Manuals, Forms and Reference Materials
Provider Manuals
Medicaid
** If you would like to receive a downloadable copy of the Medicaid provider manual, please email your request to AzCHProviderManual@azcompletehealth.com and allow up to 3 business days for a response.
Medicare
Marketplace
Reference Materials
Forms
Please note that all Provider Manual forms are available upon request by calling our Provider Customer Service line at 1-866-796-0542.
- Authorization for Release - Psychtherapy Notes - English (PDF)
- Authorization for Release - Psychtherapy Notes - Spanish (PDF)
- Authorization for Release - Psychtherapy Notes - Large Font (PDF)
- Consent to Sterilization (DOCX)
- Physical Therapy Application - Ages 21+ (PDF)
- Provider Notification of Pregnancy (PDF)
- Certificate of Pregnancy Termination (DOCX)
- Hysterectomy Consent and Acknowledgement (DOCX)
- AzCH-CCP PCP or Medical Group Change (PDF)
- Inpatient Prior Authorization Request (PDF)
- Outpatient Prior Authorization Request (PDF)
- Appeal or Serious Mental Illness Grievance Form (PDF)
- Appeal or Serious Mental Illness Grievance Form - Spanish (PDF)
- Ambetter from Arizona Complete Health DIFI Health Care Services PA Form (PDF)
- Ambetter from Arizona Complete Health DIFI Medication DME Medical Device PA Form (PDF)
- Ambetter from Arizona Complete Health Interpreter Request Form (PDF)
For Ambetter Forms and Manuals visit the Ambetter from Arizona Complete Health Provider Resources page.
All Lines of Business
- Authorization for Use or Disclosure of PHI - English (PDF)
- Authorization for Use or Disclosure of PHI - Spanish (PDF)
- Consent for Release of Information for Coordination of Care - English (PDF)
- Consent for Release of Information for Coordination of Care - Spanish (PDF)
- Inpatient and Outpatient Prior Authorization Forms