Manuals and Forms
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
- 2024 Wellcare by Allwell Provider and Billing Manual (PDF)
- 2023 Wellcare by Allwell Provider and Billing Manual (PDF)
Ambetter
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)
- Allwell Inpatient Prior Authorization Request (PDF)
- Allwell Outpatient Prior Authorization Request (PDF)
- Prior Authorization Criteria Allwell Dual Medicare (HMO SNP) and Medicare Essentials I (HMO) – English (PDF)
- Allwell Dual Medicare (HMO SNP) and Medicare Essentials I (HMO) – Spanish (PDF)
- Pharmacy PA Criteria for all other plans – English (PDF)
- Pharmacy PA Criteria for all other plans – Spanish (PDF)
- Step Therapy Criteria Step Therapy Criteria (HMO) – English (PDF)
- Step Therapy Criteria (HMO) – Spanish (PDF)
- Step Therapy Criteria (HMO D-SNP/HMO C-SNP) – English (PDF)
- Allwell here are the updated links: Prior Authorization Criteria Allwell Dual Medicare (HMO SNP) and Medicare Essentials I (HMO) – English (PDF)
- Pharmacy PA Criteria for all other plans – English (PDF)
- Pharmacy PA Criteria for all other plans – Spanish (PDF)
- Step Therapy Criteria Step Therapy Criteria (HMO) – English (PDF)
- Step Therapy Criteria (HMO) – Spanish (PDF)
- Step Therapy Criteria (HMO D-SNP/HMO C-SNP) – English (PDF)
- Step Therapy Criteria (HMO D-SNP/HMO C-SNP) – English (PDF)
- Request for Medicare Determination Form (HMO and HMO SNP)
Flyers
- Ambetter DIFI Health Care Services PA Form (PDF)
- Ambetter DIFI Medication DME Medical Device PA Form (PDF)
For Ambetter Forms and Manuals visit our Ambetter from Arizona Complete Health website
Ambetter Provider Resources
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