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Forms
Most of the documents posted on the Health Choice Arizona's Web sites are available for viewing or printing in Adobe PDF format(including Member and Provider Newsletters and the plan's forms located on the Commonly Used Forms page). If you do not have Adobe Reader installed on your computer, please download from here for free:
  Missed Medical Appointment Log Report Member No-Show to HCA Member Services: You can report member no-shows to HCA by completing the Missed Medical Appointment Log. Member Services Department will register your concerns under the member profile and will follow up with the member.
Response for request of medical records and/or IZ form Requirement for Medical Record Requests: Providers who file electronic claims or have received an EOB and want to submit medical records for review to substantiate medical necessity must complete the form above to submit with records more...
Maternal Risk Assessment FormProviders, when a member establishes prenatal care in your office, please fill out a Maternal Risk Assessment form within 30 days of seeing the member. This will help ensure that the member is assigned to your office, and claims are processed expeditiously and efficiently. If you should have any questions, please contact your Network Representative or call the HCA Stork Line (800) 828-7514. |
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EFT / ERA Information
As a convenience to our providers, Health Choice can send electronic payments to our providers utilizing Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) through our clearinghouse, Bank of America.
If you would like to participate in EFT and ERA, please complete the EFT/ERA Request form and mail or fax it to Health Choice Arizona. |
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If you have any questions, about the EFT/ERA process or how to submit a Direct Electronic Claim, please contact Health Choice at 1-800-322-8670 or (480) 968-6866 or by e-mail: HCH_Comments/HCH@iasishealthcare.com.
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