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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.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/arizona-medical-prior-authorization-form-section-submission-review-patient-information-provider-information-services-requested/287387/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/arizona-medical-prior-authorization-form-section-submission-review-patient-information-provider-information-services-requested/287387.png","ImageObject",442,249,{"name":42,"@type":43},"Connor ","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What is this form used for?","Question",{"text":62,"@type":63},"It is used to request prior authorization for applicable services that require precertification through utilization management vendor review.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"When must this form not be used?",{"text":67,"@type":63},"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.",{"name":69,"@type":60,"acceptedAnswer":70},"What sections collect patient and provider details for the request?",{"text":71,"@type":63},"The form collects subscriber and patient information in Section IV and provider details in Section V, including identifiers such as NPI and contact information.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},287387,1790196094,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":26},687207022233,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Arizona Medical Prior Authorization Form  \nApplicable Services:  \nWellfleet 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  \nDo 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.  \nFor 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 .  \nPLEASE NOTE: Determination of medical necessity will follow state specific turnaround times upon receipt of this form and all necessary information.  \nThere may be a delay if additional information is needed.  \nSECTION I – SUBMISSION  \n\n| Subscriber Name: | Phone: | Fax: | Date: |\n| --- | --- | --- | --- |\n\nSECTION II—REASON FOR REQUEST  \n\n| Review Type: □ Non-Urgent □ Urgent | Clinical Reason for Urgency: |  |  |\n| --- | --- | --- | --- |\n| Request Type: □ Initial □ Extension/Renewal/Amendment |  | Prev. Auth. \\#: |  |\n\nSECTION III—REVIEW  \n\n| | 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. |\n| --- | --- |\n| Signature of Prescriber or Prescriber’s Designee:   |  |\n\nSECTION IV—PATIENT INFORMATION  \n\n| Name: |  | Phone: | DOB: |  |  Male  Female |\n| --- | --- | --- | --- | --- | --- |\n| Member Name (if different from Section I): | Member ID \\#: |  |  | Group Name or Number: |  |\n\nSECTION V―PROVDER INFORMATION  \n\n| Requesting Provider or Facility |  | Service Provider or Facility |  |\n| --- | --- | --- | --- |\n| Name: |  | Name: |  |\n| NPI \\#: | Specialty: | NPI \\#: | Specialty: |\n| Phone: | Fax: | Phone: | Fax: |\n| Contact Name: | Phone: | Service Care Provider’s Name: |  |\n| Requesting Provider’s Signature and Date (if required): |  | Phone: | Fax: |\n\nSECTION VI―SERVICES REQUESTED (WITH CPT, CDT, OR HCPCS CODE) AND SUPPORTING DIAGNOSES (WITH ICD CODE)  \n\n| Planned Service or Procedure | Code | Start Date | End Date | Diagnosis Description (ICD version   ) | Code |\n| --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n| □ Inpatient □ Outpatient □ Provider Office □ Observation □ Home □ Day Surgery □ Other: |  |  |  |  |  |\n| □ Physical Therapy □ Occupational Therapy □ Speech Therapy □ Cardiac Rehab □ Mental Health/Substance Abuse Number of Sessions: Duration: Frequency: Other: |  |  |  |  |  |\n| □ Home Health: Order Attached? □ Yes □ No Nursing Assessment Attached? □ Yes □ No Number of Visits: Duration: Frequency: Other: |  |  |  |  |  |\n\nSECTION VII—CLINICAL DOCUMENTATION (Attach additional documentation as needed)  \nSECTION I – SUBMISSION  \n\n| Subscriber Name: | Phone: | Fax: | Date: |\n| --- | --- | --- | --- |\n\nSECTION II—REASON FOR REQUEST  \n\n| Check one: | □ Initial Request | □ Continuation/Renewal Request |\n| --- | --- | --- |\n| Reason for request: (check all that apply) □ Prior Authorization\u003Cbr>□ Step Therapy, Formulary Exception □ Medical Device\u003Cbr>□ Quantity Exception □ Durable Medical Equipment (DME)\u003Cbr>□ Specialty Drug □ Other (please specify)   |  |  |\n\nSECTION III—REVIEW  \n\n| | Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize t","cbCaiem49X90THFe","https://ap.wps.com/l/cbCaiem49X90THFe","pdf",1405115,"English","# Section I - Submission\n# Section II - Reason for Request\n# Section III - Review\n# Section IV - Patient Information\n# Section V - Provider Information\n# Section VI - Services Requested\n# Section VII - Clinical Documentation","[{\"question\":\"What is this form used for?\",\"answer\":\"It is used to request prior authorization for applicable services that require precertification through utilization management vendor review.\"},{\"question\":\"When must this form not be used?\",\"answer\":\"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.\"},{\"question\":\"What sections collect patient and provider details for the request?\",\"answer\":\"The form collects subscriber and patient information in Section IV and provider details in Section V, including identifiers such as NPI and contact information.\"}]","Arizona Medical Prior Authorization Form - Section Submission - Review - Patient Information - Provider Information - Services Requested | PDF",1789632274]