Forms
- AZ Blue Member Appeal/Grievance Packet – for most commercial group plans and grandfathered and grandmothered individual/family plans
- ACA Member Appeal/Grievance Packet – for ACA individual/family plans
- Self-Funded Group Appeal/Grievance Packet - for some self-funded employer groups, except those that have their own customized appeal packets, including:
- State of Arizona (group 30855; member ID prefixes SYD and S3Z)
- Teamsters (groups 31843 and 31844; member ID prefix TYW)
- U-Haul (group 026229; member ID prefix UHL) – see the member benefit book
- Appeal and Grievance Request Form
- Provider Certification Form for Expedited Appeal
- Authorized Representative Designation Form
Need help? Call 602-544-4938 or 1-866-595-5998.
Medicare Advantage Member Appeal/Grievance Forms- CMS Appointment of Representative form (CMS-1696): Access from the CMS Forms List.
- Corrected Claim Form (PDF)
- Non-Contracted Provider (PDF)
- Notice of Excess Payment (PDF)
EFT (Electronic Funds Transfer)
We’ve moved our EFT form to the Availity Essentials provider portal.
Not registered yet? Visit Availity’s Register and Get Started page.
EFT Form - Provider FAQs (PDF)
EFT Enrollment and Changes – Instructions (PDF)
ERA (Electronic Remittance Advice)
ERA Enrollment/Change Form (PDF)
ERA Enrollment/Change - Instructions (PDF)
- Credentialing/Contracting - To check if a provider is already credentialed/contracted, use the Provider Directory.
- Medical Practitioner-Initial Credentialing Request Form (use this form only for providers not yet participating with AZ Blue; for network provider updates, including adding a tax ID, use the Provider Information Change Form)
- Facility/Ancillary Provider Cred/Contract Request Form (also use this form to add a new location; for other updates, use the Provider Information Change Form)
- Facility Specialty Form (required for all facilities)
- Behavioral Health Outpatient Facility Questionnaire/Attestation (required if applicable)
- Behavioral Health Sub-Acute Inpatient Facility Questionnaire/Attestation (required if applicable)
- Medical Group Contract Request Form (for new groups)
- Dental Provider Cred/Contract Request Form
- Chiropractic Providers: Call 888-511-2743 or visit the ASH Provider Network page
- Note: Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum. For more information, reach out to your Provider Relations Contact
- TriWest Healthcare Alliance Networks for veterans
- Requires AZ Blue credentialing (see forms above) and a completed TriWest Contract Request Form
- Changes to Provider Information
- Contract Termination
- Termination Form (to terminate your network contract or terminate an affiliation with a tax ID)
- No Surprises Act Information and Forms (Resource Page)
- Prior Authorization Request Forms (Resource Page)
To bill members with AZ Blue commercial plans for services considered investigational or not medically necessary, obtain informed consent and a written waiver of billing restrictions, such as this form: Waiver of Billing Restrictions Form - commercial plans only (PDF)
Note: Use this form for members with AZ Blue commercial plans only. This form is not applicable for commercial plans administered by a third-party administrator (TPA) or another Blue Plan (BlueCard out-of-area plans), and Medicare Advantage plans (CMS requires a pre-service determination and notice of denial).