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Provider Manual Forms & Attachments

ALL PROVIDERS:  Please call the Provider Services Call Center at 1-866-796-0542 for a copy of any Forms or Attachments listed below.

2.2 Maternity Services

  • 2.3.2  Notification of Pregnancy (NOP)

12.7 General and Informed Consent to Treatment

  • Provider Manual Form 3.7.1 General Consent to Treatment
  • Provider Manual Form 3.7.1 General Consent to Treatment - Spanish

12.13 Out-of-State Placements for Children and Young Adults

  • Provider Manual Form 3.13.1 Out-of-State Placement, Initial Notice and 30 day Update

3.17 Behavioral Health Home Provider Requirements

  • Provider Manual Form 3.17.3, Birth through Five High Needs Screening Tool

13.1 Transition of Persons

  • Provider Manual Form 4.1.1 Inter-Agency Transfer & Transition Checklist

13.2 Inter-RBHA Coordination of Care

  • Provider Manual Form 4.2.1 AzCH-CCP Outgoing Transfer Request for SMI or CMDP Members
  • Provider Manual Form 4.2.3 AZ Complete Health Authorization for Release-Generic

14.1 Urgent Response Disposition

  • Provider Manual Form 6.1.1 Urgent Response Disposition

10.9 Seclusion and Restraint Reporting

4.1 Securing Services and Prior Authorization/Retrospective Authorization

  • Provider Manual Form 10.1.1 Certification of Need (CON)
  • Provider Manual Form 10.1.2 Recertification of Need (RON)
  • Provider Manual Form 10.1.3 Notice of Admission to ALL LEVELS OF CARE
  • Provider Manual Form 10.1.6 Concurrent Review
  • Provider Manual Form 10.1.8 Pre-Authorization Out-of-Home
  • Provider Manual Form 10.1.12 Outpatient Medicaid Prior Authorization Fax Form
  • Provider Manual Form 10.1.13 Inpatient Medicaid Prior Authorization Fax Form
  • Provider Manual Form 10.1.14 Intensive Staff - CCR
  • Provider Manual Form 10.1.15 Out-of-Network Request
  • Provider Manual Form 10.1.16 Notice of Temporary Placement MASTER
  • Provider Manual Form 10.1.17 Notice of Transfer Out of Home Facilities MASTER

13.3 Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers

  • Provider Manual Form 13.3.1 Request for Information from PCP or Medicare Provider
  • Provider Manual Form 13.3.2 PCP Communications Document

Securing Services and Prior Authorization/Retrospective Authorization

  • Provider Manual Attachment 10.1.1 Admission Psychiatric Acute Hospital & Sub-Acute Criteria,
  • Provider Manual Attachment 10.1.2 Continued Psychiatric Acute or Sub-Acute Facilities Authorization Criteria,
  • Provider Manual Attachment 10.1.3 Prior Authorization Criteria for Admission and Continued Stay for Behavioral Health Residential Facilities,
  • Provider Manual Attachment 10.1.3a BHRF Substance Abuse Treatment Placement FAQs,
  • Provider Manual Attachment 10.1.4 Prior Authorization Criteria for Admission and Continued Stay for Behavioral Health Supportive Homes,
  • Provider Manual Attachment 10.1.5 Prior Authorization Criteria for Continued Stay for HCTC
  • Provider Manual Attachment 10.1.6 Authorization Criteria for Behavioral Health Inpatient Facilities
  • Provider Manual Attachment 10.1.15 Prior Authorization Criteria for HCTC

6.1 Enrollment, Disenrollment and Other Data Submission

  • Provider Manual Attachment 13.1.1 834 Transaction Data Requirements

9.3 Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits

  • Provider Manual Attachment 12.2.1, Documents Accepted by AHCCCS to Verify Citizenship and Identity
  • Provider Manual Attachment 12.2.2, Citizenship/Lawful Presence Verification Process Through Health-e-Arizona PLUS
  • Provider Manual Attachment 12.2.3, Persons Who Are Exempt From Verification of Citizenship During the Prescreening and Application Process
  • Provider Manual Attachment 12.2.4, Non-Citizen/Lawful Presence Verification Documents

10.9 Seclusion and Restraint Reporting

  • Provider Manual Attachment 9.9.1 Seclusion and Restraint Reporting Form

12.2  Appointment Standards and Timeliness of Service

  • Provider Manual Attachment 3.2.1 DCS Child Welfare Timelines

12.5  Assessment and Service Planning

  • Provider Manual Attachment 3.5.1 Service Plan Rights Acknowledgement Template
  • Provider Manual Attachment 3.5.8 Functional Behavioral Assessment Guidance Document

12.8  Psychotropic Medication: Prescribing and Monitoring

  • Provider Manual Attachment 3.8.5 Minimum Laboratory Monitoring for Psychotropic Medications

12.11 Special Assistance for Persons Determined to Have Serious Mental Illness

  • Provider Manual Attachment 3.11.1 Special Assistance Guidance Document

13.4  Coordination of Care with Other Governmental Entities

  • Provider Manual Attachment 4.4.2 Consultation & Clinical Intervention (CCI) Program Requirements