Medical Documentation Form

The Medical Documentation Form The Medical Documentation Form is to be utilized when submitting additional documentation that has not been previously submitted and is needed to substantiate medical necessity and appropriateness of services requested. This form should also be used when submitting additional documentation for concurrent review or when a Prior Authorization has been pended requesting additional documentation.

Medical Documentation Form  [PDF, 61KB]

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.