Prior Authorization Request Form

The Prior Authorization Request Form is to be completed by registered providers to request an initial authorization. Providers should submit any medical documentation needed for the authorization to be considered with this form. The form must be completed in its entirety.

Prior Authorization Request Form [PDF]

 

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.

 

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