Get the free FEE-FOR-SERVICE AUTHORIZATION REQUEST FORM - AHCCCS - azahcccs

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Janice K. Brewer, Governor Thomas J. Beach, Director 801 East Jefferson, Phoenix, AZ 85034 PO Box 25520, Phoenix, AZ 85002 Phone: 602-417-4000 www.azahcccs.gov Our first care is your health care ARIZONA

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What is fee-for-service authorization request form?

The fee-for-service authorization request form is a document used to request approval for a fee-for-service healthcare service or treatment.

Who is required to file fee-for-service authorization request form?

Healthcare providers or individuals seeking fee-for-service healthcare services are required to file the authorization request form.

How to fill out fee-for-service authorization request form?

To fill out the fee-for-service authorization request form, provide all required personal information, details of the requested service or treatment, and any supporting documentation as specified.

What is the purpose of fee-for-service authorization request form?

The purpose of the fee-for-service authorization request form is to obtain approval for fee-for-service healthcare services or treatments, ensuring proper coverage and reimbursement.

What information must be reported on fee-for-service authorization request form?

The fee-for-service authorization request form typically requires reporting of personal information, healthcare provider details, diagnosis codes, procedure codes, requested services, supporting documentation, and any other relevant information specified.

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