Arizona Medical Prior Authorization Form - Section Submission - Review - Patient Information - Provider Information - Services Requested

Sep 17, 2026

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Arizona Medical Prior Authorization Form for services requiring precertification through utilization management. Defines applicable review context, clarifies when the form must not be used for appeals, eligibility or coverage confirmation, prior authorization questions, prescription drug requests, or referrals out of network. Includes sections to submit subscriber details, request type and review urgency, clinical certification for expedited review, patient and prescriber information, provider identifiers, and a detailed services table with CPT/CDT/HCPCS and ICD-based diagnoses.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Section I - Submission

Section II - Reason for Request

Section III - Review

Section IV - Patient Information

Section V - Provider Information

Section VI - Services Requested

Section VII - Clinical Documentation

Arizona Medical Prior Authorization Form Applicable Services: Wellfleet utilizes utilization management (UM) vendors for services that require precertification. Clinical review criteria and information on how to submit pre-certification requests to UM vendors may be found [https://wellfleetstudent.com/providers/](https://wellfleetstudent.com/providers/ under Other)[ under](https://wellfleetstudent.com/providers/ under Other)[ Other](https://wellfleetstudent.com/providers/ under Other)[ ](https://wellfleetstudent.com/providers/ under Other)Provider Resources Do not use this form: 1) to request an appeal, 2) to confirm eligibility, 3) to verify coverage, 4) to ask whether a service requires prior authorization, 5) to request prior authorization of a prescription drug, or 6) to request a referral to an out of network physician, facility, or other health care provider. For further information or questions, please call the phone number listed on the back of the customer’s ID card or call the Customer Service team (800)633-7867 . PLEASE NOTE: Determination of medical necessity will follow state specific turnaround times upon receipt of this form and all necessary information. There may be a delay if additional information is needed. SECTION I – SUBMISSION | Subscriber Name: | Phone: | Fax: | Date: | | --- | --- | --- | --- | SECTION II—REASON FOR REQUEST | Review Type: □ Non-Urgent □ Urgent | Clinical Reason for Urgency: | | | | --- | --- | --- | --- | | Request Type: □ Initial □ Extension/Renewal/Amendment | | Prev. Auth. \#: | | SECTION III—REVIEW | | Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. | | --- | --- | | Signature of Prescriber or Prescriber’s Designee: | | SECTION IV—PATIENT INFORMATION | Name: | | Phone: | DOB: | | Male Female | | --- | --- | --- | --- | --- | --- | | Member Name (if different from Section I): | Member ID \#: | | | Group Name or Number: | | SECTION V―PROVDER INFORMATION | Requesting Provider or Facility | | Service Provider or Facility | | | --- | --- | --- | --- | | Name: | | Name: | | | NPI \#: | Specialty: | NPI \#: | Specialty: | | Phone: | Fax: | Phone: | Fax: | | Contact Name: | Phone: | Service Care Provider’s Name: | | | Requesting Provider’s Signature and Date (if required): | | Phone: | Fax: | SECTION VI―SERVICES REQUESTED (WITH CPT, CDT, OR HCPCS CODE) AND SUPPORTING DIAGNOSES (WITH ICD CODE) | Planned Service or Procedure | Code | Start Date | End Date | Diagnosis Description (ICD version ) | Code | | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | □ Inpatient □ Outpatient □ Provider Office □ Observation □ Home □ Day Surgery □ Other: | | | | | | | □ Physical Therapy □ Occupational Therapy □ Speech Therapy □ Cardiac Rehab □ Mental Health/Substance Abuse Number of Sessions: Duration: Frequency: Other: | | | | | | | □ Home Health: Order Attached? □ Yes □ No Nursing Assessment Attached? □ Yes □ No Number of Visits: Duration: Frequency: Other: | | | | | | SECTION VII—CLINICAL DOCUMENTATION (Attach additional documentation as needed) SECTION I – SUBMISSION | Subscriber Name: | Phone: | Fax: | Date: | | --- | --- | --- | --- | SECTION II—REASON FOR REQUEST | Check one: | □ Initial Request | □ Continuation/Renewal Request | | --- | --- | --- | | Reason for request: (check all that apply) □ Prior Authorization
□ Step Therapy, Formulary Exception □ Medical Device
□ Quantity Exception □ Durable Medical Equipment (DME)
□ Specialty Drug □ Other (please specify) | | | SECTION III—REVIEW | | Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize t

FAQs

What is this form used for?

It is used to request prior authorization for applicable services that require precertification through utilization management vendor review.

When must this form not be used?

Do not use it for appeals, eligibility confirmation, coverage verification, questions about whether prior authorization is needed, prescription drug prior authorization requests, or referral requests to out-of-network physicians, facilities, or other providers.

What sections collect patient and provider details for the request?

The form collects subscriber and patient information in Section IV and provider details in Section V, including identifiers such as NPI and contact information.

Sep 17, 2026

Upload by Connor