Prior Authorization and Referral Forms

 

Behavioral Health

AZPC Behavioral Health will provide access to outpatient professional Behavioral Health services. Including Psychiatry by Psychiatrists (MD) and Psychiatric Nurse Practitioners (NP) and Psychotherapy/Cognitive Behavioral Therapy by Psychologists (PhD/PsyD) and Licensed Clinical Social Workers (LCSW). Please call 833-633-0043 (members & referring providers)

BH Initial Request for Treatment Authorization Form

BH Follow-Up Request for Treatment Authorization Form

AZPC Behavioral Health will manage the Inpatient Behavioral Health and Substance Use Disorder Care including the Utilization Management of inpatient stays, and all Behavioral Health and Substance Use Disorder case management. Please call 833-633-0042 (providers & hospitals)

 

Provider Forms

 

HCC Forms

 

Claims and Billing

 

Other Forms

 

Resources and Links

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