Commonly Used Forms

On occasion AFMC will ask you to complete forms for specific items. You may fill out and print the necessary form(s) by clicking on your selection below.

To obtain a form by fax or e-mail, contact AFMC's Call Center, between the hours of 8 am - 5 pm, Monday - Friday, Mountain Standard Time.

Providers

• Privacy Notice Form.pdf

  AFMC is happy to offer the physician community and their patients the convenience of filling out and printing the "Authorization for Use or Disclosure of Protected Health Information" form on-line. The process is easy. Simply click on the pdf above, read the directions, fill out the form, print, sign and return to AFMC. It's as simple as that!

• General Registration and Claims Status
• Delegated Provider Change Form.pdf

  GROUP Providers should use this form to notify Arizona Foundation of provider changes, such as address, phone or email.

• Fee Schedule Request Form

  Use this form to request a fee schedule from AFMC. Simply click on the pdf above, read the directions, fill out the form, print, sign and return to AFMC. Don't forget the required documentation we need to process the form!

• Provider Change Form.pdf

  A form to keep AFMC informed about current practice information such as a change of address, Tax ID#, or specialty change.

Payors

• Administrator Electronic Billing Form.pdf
• Agreement for Services Abstract
• Privacy Notice Form.pdf

  AFMC is happy to offer the physician community and their patients the convenience of filling out and printing the "Authorization for Use or Disclosure of Protected Health Information" form on-line. The process is easy. Simply click on the pdf above, read the directions, fill out the form, print, sign and return to AFMC. It's as simple as that!

• ID Card Standards.pdf
• New Business Transmittal
• New Business Transmittal Employees Outside Arizona.pdf
• Renewal Rates Form.pdf

  Is it time for your client to renew their contract with AFMC? Do you want to inquire about their rates for the new contract? Use the Renewal Rates Form.

• Revision Notice In-Force Business.pdf