Fillable Printable Fee-For-Service Authorization Request Form

Fee-For-Service Authorization Request Form

Douglas A. Ducey, Governor

Thomas J. Betlach, Director

801 East Jefferson, Phoenix, AZ 85034

PO Box 25520, Phoenix, AZ 85002

Phone: 602-417-4000

www.azahcccs.gov

♦ RECIPIENT NAME: ♦ AHCCCS ID (9 digits): A

♦ PROVIDER NAME:

♦ PRIOR AUTHORIZATION #:

♦ PROVIDER PHONE #: ♦ PROVIDER NPI: (10 digits)

♦ PROVIDER FAX #: ♦ AHCCCS ID: (6 digits)

♦ DIAGNOSIS: ♦ DATES OF SERVICE:

(Transportation Use R68.89)

*CPT/HCPCS/

Units:

ICU

Date:

Routine

*If CPT/HCPCS are BR (Non-Capped) price is needed (Code/Price):

TRANSPORT:

REASON FOR TRIP:

COMMENTS:

Return Fax # Prior Authorization 602-256-6591 Transportation 602-254-2431 LTC 602-254-2426 BHS 602-364-4697

REV Code

Behavioral Health

I/P

TRBHA

BHS Other

CDT/

Assisted Living-Behavorial Health

Therapy

Home Health

DME

Home Modification

Tribal ALTCS

Above Level of Care

7/1/2016

Tiers:

FEE-FOR-SERVICE AUTHORIZATION REQUEST FORM

Dental

♦ TYPE OF ACUTE SERVICE REQUESTED

♦ Mandatory Fields must be completed or information will be returned.

(One Member Per Form Please)

Beds

NF (Special Rates)

Transportation

LTC Acute

Prior Authorization

DME

Acute Medical I/P MR#

Acute Medical O/P MR#

Surgical Request

TRIP COUNT:

Modifier:

TRIP FROM:

(Atypical Providers Only)

TRIP TO:

(One Way=1 Round Trip=2)