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Plan Documents, Claim Forms and Provider Information

All the forms you need can be found right here. Simply select the form you want and you'll be able to download and print a ready-to-use version.

Please note: Select only the forms appropriate to the coverage(s) in which you are enrolled.

EPO Plan Description	RAN+AMN EPO Plan Description	Use this information for a complete outline of EPO Plan benefits.
PPO Plan Description	Arizona Foundation PPO and Beech Street PPO Plan Description	Use this information for a complete outline of PPO plan benefits.
Guidelines for $10 and $20 copays	Explanation of which copay applies	Use this information for a overview of which copay applies to physician services.
Oct. 2007 Plan Changes	Overview of plan changes	Use this information for an explanation of plan changes effective Oct. 2007.
Arizona Foundation Medical Claim Form	Mail Claim To: Arizona Foundation for Medical Care P.O. Box 2909 Phoenix, AZ 85062-2909 Customer Service Number: 1-888-999-1459	Use this form when submitting for reimbursement on your medical services.
RAN+AMN, Beech Street Form	Mail Claim To: AZ Benefit Options - UMR P.O. Box 30538 Salt Lake City, UT 84130-0538 Customer Service Number: 1-888-999-1459	Use this form when submitting for reimbursement on your medical services.
WHI Reimbursement Form	Mail Claim To: Walgreens Health Initiatives P.O. Box 545 Deerfield, IL 60015	Use this form when submitting for reimbursement on your prescription services.
Foreign Travel Guidelines	Guidelines for services outside the U.S.	The following information is provided to outline the benefits available under the AZ Benefit Options plans.
Services Outside Arizona and within the U.S.	Guidelines for services outside the state of Arizona and within the U.S.	The following information is provided to outline the benefits available under the AZ Benefit Options plans.
TOC Form	Transition of Care (TOC) request form.	Use this form when requesting an approval for transition of care to a network provider.

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