Forms
- Member Appeals 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)
- Corrected Claim Form (PDF)
- Non-Contracted Provider (PDF)
- Notice of Excess Payment (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
- No Surprises Act Information and Forms (Resource Page)
- Covering PCPs Form (PDF)
- PCP Consent Form (PDF)
- Prior Authorization Request Forms (Resource Page)