ARIZONA STANDARDIZED PRIOR AUTHORIZATION REQUEST FOR MEDICATION, DME, AND MEDICAL DEVICE - Submission Form

Sep 17, 2026

Arizona standardized prior authorization request form for medication, durable medical equipment (DME), and medical devices. The document collects subscriber and patient details, prescriber and ordering provider information, and whether the request is initial or continuation/renewal. It captures expedited/urgent review certification, requested drug details including compound ingredients, DME/device information, and patient clinical data such as diagnosis, ICD codes, prior drugs, allergies, relevant labs, and attached justification notes.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Section I – Submission

Section II—Reason for Request

Section III—Review

Section IV—Patient Information

Section V—Prescriber/Ordering Provider Information

Section VI—Prescription Drug Information

Section VII—Prescription Compound Drug Information

Section VIII—Prescription DME or Medical Device Information

Section IX—Patient Clinical Information

Section X—Justification

ARIZONA STANDARDIZED PRIOR AUTHORIZATION REQUEST FOR MEDICATION, DME, AND MEDICAL DEVICE 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
□ Medical Device
□ Durable Medical Equipment (DME)
□ Other (please specify) | | | □□
□ | Step Therapy, Formulary Exception
Quantity Exception
Specialty Drug | | | | 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 | | | | --- | --- | --- | --- | --- | --- | --- | --- | | Address: | | City: | | | | State: | ZIP Code: | | Subscriber Name (if different from Section I): | Member ID \#: | | | Group Name or Number: | | | | | BIN \# (if available): | PCN (if available): | | | Rx ID \# (if available): | | | | SECTION V―PRESCRIBER/ORDERING PROVDER INFORMATION | Name: | | NPI \#: | Specialty: | | | | --- | --- | --- | --- | --- | --- | | Address: | | City: | | State: | ZIP Code: | | Phone: | Fax: | Office Contact Name: | | Contact Phone: | | SECTION VI―PRESCRIPTION DRUG INFORMATION (If this is a compound drug, identify all ingredients in Section VI, below.) | Requested Drug Name: | | | | | | --- | --- | --- | --- | --- | | Strength: | Route of Administration: | Quantity: | Days’ Supply: | Expected Therapy Duration: | | To the best of your knowledge this medication is:
□ New therapy □ Continuation of therapy (approximate date therapy initiated: ) | | | | | | For Provider Administered Drugs Only:
HCPCS Code: NDC \#: Dose Per Administration: | | | | | SECTION VII—PRESCRIPTION COMPOUND DRUG INFORMATION | Compound Drug Name: | | | | | | | --- | --- | --- | --- | --- | --- | | Ingredient | NDC \# | Quantity | Ingredient | NDC \# | Quantity | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | SECTION VIII—PRESCRIPTION DME or MEDICAL DEVICE INFORMATION | Requested DME or Medical Device Name: | Expected Duration of Use: | HCPCS Code (If applicable): | | --- | --- | --- | SECTION IX—PATIENT CLINICAL INFORMATION | Patient’s diagnosis related to this request: | ICD Version: | ICD Code: | | --- | --- | --- | | Patient’s diagnosis related to this request: | ICD Version: | ICD Code: | Drugs patient has taken for this diagnosis: (Provide the following information to the best of your knowledge) | Drug Name | Strength | Frequency | Dates Started and Stopped or Approximate Duration | | Describe Response, Reason for Failure, or Allergy | | | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Drug Allergies: | | | | Height (if applicable): | | Weight (if applicable): | Relevant laboratory values and dates (attach or list below): | Date | Test | Value | | --- | --- | --- | | | | | | | | | | | | | | | | | SECTION X―JUSTIFICATION (Provide or attach any additional justification here: Notes, Treatment plans, lab/test results, etc) ARIZONA RX/DME PRIOR AUTHORIZATION FORM 12/01/2021 Page 2 of 2

FAQs

What sections are required to submit this prior authorization request?

Submission is organized into Section I through Section X, including subscriber/patient information, reason for request, prescriber details, drug or DME/device details, patient clinical information, and a justification section for supporting notes and attachments.

How does the form indicate whether the request is initial or a continuation/renewal?

In Section II, it provides checkboxes for “Initial Request” and “Continuation/Renewal Request,” and the applicant selects the applicable option.

When is expedited/urgent review requested, and what is required?

Section III allows expedited/urgent review by checking the box and providing a signed certification from the prescriber or designee stating that standard review timing may seriously jeopardize the patient’s life or health.

Sep 17, 2026

Upload by Sophia Brooks