Federal Emergency Services Program (FESP) Dialysis Authorization Forms

Initial Dialysis Case Creation Form

The Initial Dialysis Case Creation Form is the first form that is completed by registered providers to establish a Federal Emergency Services Program (FESP) member on the Extended Service Program. This program provides any dialysis related services for the member's End Stage Renal Disease (ESRD). The form must be completed in its entirety.

Initial Dialysis Case Creation Form [PDF, 15KB]

Monthly Certification of Emergency Medical Condition

The Monthly Certification Form is for the Federal Emergency Services Program (FESP) member. The program provides for the dialysis related care for the member's End Stage Renal Disease (ESRD).

Monthly Certification of Emergency Medical Condition [Word, 27KB]

This form provided must be completed monthly, maintained in the member's file at your office, and be available to AHCCCS on request if needed.

Contacts

You may phone or fax the AHCCCS Prior Authorization Unit to request authorization.

To obtain a prior authorization by telephone, providers must call Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm.

• Within Maricopa County: 602-417-4400, Select option 1 for transportation
• Statewide: 1-800-433-0425
• Outside Arizona: 1-800-523-0231
• FESP Dialysis: 602-417-7548

The AHCCCS Prior Authorization Unit's fax number is 602-256-6591.

Allow at least three working days for your request to be processed.