Provider Forms, Programs and References

• Children's Rehabilitative Services Designation Application
  

• AHCCCS Medical Policy Manual (AMPM) (azahcccs.gov)
  

External Guidelines and Resources

• Agency for Healthcare Research and Quality (AHRQ) - A division of the U.S. Department of Health & Human Services that is the lead Federal agency charged with improving the safety and quality of America's health care system. 
  
• American College of Obstetricians and Gynecologists (ACOG) - ACOG members can sign in to access required forms.
  
• American College of Obstetricians and Gynecologists Practice Guidelines for Long-Acting Reversible Contraception (LARC)
  
• Arizona Department of Education - Promotes the development and implementation of quality education for students with disabilities
• Arizona Department of Health Services - Arizona Department of Health Services website has a comprehensive list of services provided.
  
• Arizona Department of Health Services Clinician Guidelines
• AHCCCS Chapter 10 Federally Qualified Health Centers (FQHC) / Rural Health Clinic (RHC) Addendum - A list of the Community Health Centers (CHCs) including Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) that participate with AHCCCS. AHCCCS members may select one of the FQHCs and/or RHCs as their primary care physician.
  • Performance Measures for AHCCCS - Performance Measures as defined by AHCCCS.
• AHCCCS EPSDT Periodicity Schedule, Attachment A
• AHCCCS Information Regarding Children’s Rehabilitative Services (CRS) Designation and Guidelines
• AHCCCS Online Member Verification and Eligibility - How to register and access AHCCCS member eligibility information. 
• AHCCCS Provider and Member Surveys
• AHCCCS Provider Enrollment Portal
• AHCCCS Report Suspected Fraud or Abuse of the Program Online Form - Report suspected fraud or abuse of the program to the State of Arizona.
  
• AHCCCS Targeted Investments - The Targeted Investments Program is AHCCCS’ strategy to provide financial incentives to eligible AHCCCS providers to develop systems for integrated care.  
  
• Best Available Evidence Policy - The Best Available Evidence policy requires Medicare Part D sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.
• Centers for Medicare and Medicaid Services (CMS) - The Centers for Medicare & Medicaid Services is a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA, and CLIA.
• Children's Rehabilitative Services (CRS) Forms & Resources
• Department of Health & Human Services - U.S. Department of Health & Human Services official website.
• Division of Developmental Disabilities - provides health care services to eligible Arizonans through its role as a Managed Care Organization in the State Medicaid system 
• Division of Developmental Disabilities - Online Fraud, Waste or Abuse Reporting Form - Report suspected fraud or abuse of the program to the Division of Developmental Disabilities (DDD)
• Health Information Portability and Accountability Act (HIPAA) - HIPAA information for professionals regarding privacy, security, transactions and code sets, and national identifiers resource on regulations and compliance for the healthcare industry.
  
• Healthfinder - Healthfinder has been recognized as a key resource for finding the best government and nonprofit health and human services information on the Internet. Healthfinder links to carefully selected information from over 1,700 health-related organizations.
• Immunization Schedules - Recommended immunization schedules from the Centers for Disease Control and Prevention (CDC) for children, adolescents and adults.
• Low-Cost / No-Cost Clinic Resources in Arizona - Sliding Fee Schedule (SFS) clinics throughout Arizona that provide free or low cost primary, mental and dental health services to persons without health insurance.
  
• medicare.gov - The official U.S. government website for people with Medicare coverage.
• Pediatric Care Guidelines - The American Academy of Pediatrics is an organization of 66​,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.​
• Pre-Petition Screening, Court Ordered Evaluation and Court Ordered Treatment 
  
  • Application for Involuntary Evaluation
    
  • Application for Emergency Admission for Evaluation
    
  • Application for Voluntary Evaluation
    
  • COE Affidavit
    
  • Petition for Court-Ordered Evaluation
    
  • Petition for Court-Ordered Treatment Gravely Disabled Person
• School Administrator Resource - Behavioral Health Providers - A resource for partnering with Behavioral Health Providers.
• The Society for Post-Acute and Long-Term Care Medicine (formerly American Medical Directors Association) - Organization dedicated to excellence in patient care and provides education, advocacy, information, and professional development to promote the delivery of quality long term care medicine.
  
• Washington Publishing Company Code List - Access to Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC). 

Health Current is the health information exchange (HIE) that helps partners transform care by bringing together communities and information across Arizona.

Forms 

• AHP Organization Facility Credentialing Form
  
• AHP Practitioner Data Form
• AHP Practitioner/Practice Change Form
• Appointment of Representative
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Clinical Sample Templates
  
• Hysterectomy Consent and Acknowledgement Form
• IHS Primary Care Physician PCP Referral Form 
  While members may request services from an In-Network Provider without a referral, the Physician may use this Referral Form as needed.
• Pregnancy Notification Form
  We know that sending faxes can be time-consuming and challenging, especially since many practices have staff that are working from home. To support your efforts to notify UnitedHealthcare of pregnant patients, you can now use a new tool in the UnitedHealthcare Provider Portal, Care Conductor and Notification of Pregnancy. New to UnitedHealthcare Provider Portal? In order to get access to the UnitedHealthcare Provider Portal, please visit UHCprovider.com/newuser
• Primary Care Provider PCP Change Request Form
  Use this form for UnitedHealthcare Community Plan members who want to change their primary care provider.
• Synagis Enrollment Form
  

Guides, toolkits and resources for medical providers which includes both adult and youth screening tools.  

• 2023 UnitedHealthcare Community Provider Satisfaction Survey
• Autism Spectrum Disorder Provider List 
  
• Autism Spectrum Disorder Toolkit  - The Behavioral Health toolkit includes assessment tools, screening tools, behavioral health guidelines, identifying in-network referrals and health information for patients. 
• Behavioral Health Toolkit for Medical Providers - The Behavioral Health toolkit includes assessment tools, screening tools, behavioral health guidelines, identifying in-network referrals and health information for patients.
• Health Care for Individuals with Intellectual and Developmental Disabilities
• Medicaid Dental Quick Reference Guide
• Transfer of Behavioral Health Care from Primary Care Physician (PCP) to the Regional Behavioral Health Authorities (RBHA) - When a patient is transferred from a PCP to a RBHA network physician for ongoing behavioral health care, it is required that the PCP coordinate this transfer of care.
• UnitedHealthcare Community Plan of Arizona Care Provider EPSDT Toolkit
• UnitedHealthcare Community Plan Quick Reference Guide