Forms

• Standard Appeal/Grievance Packet 1 – For most AZ Blue members (PDF)
• Standard Appeal/Grievance Packet 2 – For self-funded employer groups (PDF)
• Custom Packet for State of Arizona – Prefixes SYD and S3Z; Group 30855 (PDF)
• Custom Packet for Teamsters – Prefix TYW; Groups 31843 and 31844 (PDF)
• Standard Appeal/Grievance Request Form (PDF)
• Provider Certification Form for Expedited Appeal (PDF)
• Authorized Representative Designation Form (PDF)
• CMS Webpage-Forms List - For Appointment of Representative Form (CMS-1696)

• Provider Grievance Form (PDF)
• No Surprises Act (NSA) Forms and Information (AZ Blue Webpage)

• Care Management Referral Form (PDF)
• Care Management Referral Online Form (Online)

• Corrected Claim Form (PDF)
• Non-Contracted Provider (PDF)
• Notice of Excess Payment (PDF)

• AZ Blue Member COB Information Form (PDF)
• BlueCard (Out-of-Area) Member COB Information Form (PDF)
• Medicare Advantage Member COB Information Form (PDF)

• EFT Enrollment - Provider FAQs (PDF)
• EFT Enrollment/Change Process – Instructions (PDF)
• ERA Enrollment/Change Form (PDF)
• ERA Enrollment/Change - Instructions (PDF)

• Mental Health Parity Disclosure Request Form (PDF)

Use the following forms to request contracting/credentialing and to add a tax ID to your contract. To update other provider information, please use the Provider Information Change Form.

• Dental Contract-Credentialing Form – Requires a CAQH Dental profile and number
• Facility/Professional Group/Ancillary Contract-Credentialing Form – Also use this form to add a tax ID (PDF)
• Medical Professional-Individual Contract-Credentialing Form – Requires a CAQH profile and number
  Also use this form to add a tax ID to your contract
Notes:
• If you are a PT/ST/OT professional and are part of a group, your group must have a group contract on file with us before we can complete your credentialing.
• Chiropractors must apply through American Specialty Health (ASH) at 1-888-511-2743.
• Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum.

• TriWest Health Alliance Network (for Veterans) 
  • To request a contract for the TriWest Healthcare Alliance Network, please visit the TriWest contracting page.
  • If you already have a contract with TriWest and would like to be credentialed or update your contract, please complete the above facility or professional forms.
• Contract Termination Form

• Non-Contracted Provider Information Form (PDF)

• No Surprises Act Information and Forms (Resource Page)

• Covering PCPs Form (PDF)
• PCP Consent Form (PDF)

• PCMH Program Interest Form (PDF)

• Prior Authorization Request Forms (Resource Page)

• Dental Providers-Information Change Form (PDF)
• Medical Providers-Information Change Form (Online)
• Non-Contracted Providers-Information Change Form (PDF)

• Waiver of Billing Restrictions Form (PDF)