Toll Free: 800.747.7997

Forms

Phoenix Health Plan makes it easy to find the forms you need.

If you don't find a form you require, please call us at:

Phoenix Health Plan
(602) 824-3700 or
(800) 747-7997

Claims

Submit online claim questions

• Electronic Funds Transfer (EFT) Form
• W-9 Form

Provider Information

• Claims Dispute Form
• PCP Discharge Letter
• Member No Show Log

Credentialing

• Letter of Intent to Participate
  

Dental Referrals

• Dental Specialist Referral Form

EPSDT

• EPSDT AHCCCS Tracking Form Order Sheet
• AHCCCS EPSDT Tracking Forms

OB Services

• Federal Consent Sterilization Form
• Newborn Reporting From - Hospital Use

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Last Updated on 7/1/2011

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7878 North 16th Street, Suite 105
Phoenix, AZ 85020
602.824.3700 or 1.800.747.7997