Forms for Members
Below are links which provide printable
versions of CRS forms for Members. Questions about how to use these
forms should be directed to CRS. Phone number 602-406-6400 or email
by clicking on the Contact Us field at the top of this page.
CRS Application
form
The link below will provide a
printable version of the CRS enrollment application form. If
you are not a CRS member and believe and need apply,
please contact a member of the CRS Managed Care team and they will
assist you in completing the application.
CRS
Application
Arizona Residency
form
The link below provides a
printable version of the Arizona Residency form. This form is
signed my CRS applicants to declare their Arizona
Residency.
Arizona
Residency
Member Payment
Agreement form
The link below
provides a printable version of the Member Payment Agreement form.
This form is used for payment related information. The information
includes payment percentage and release of
information.
Member
Payment Agreement
Member Payment
Responsibility Worksheet
The second
authorizes CRS to release information necessary for the completion
of hospital, other providers, and medical insurance
claims.
Member
Payment Responsibility
Forms for Providers
Below are links which provide printable
versions of various CRS forms for Providers. Questions about
how to use the forms should be directed to CRS by phone
602-406-6400 or email your question by clicking on the contact us
field at the top of this page.
Provider Service
Request (PSR) form
The PPSR form is completed by providers requesting authorization
for services to CRS patients. A printable version of the PSR form
can be obtained by clicking the link below
Provider
Services Requisition
Provider Service
Request Change (PSRC) form
The PSRC form is completed by providers requesting a change in
authorization for services to CRS patients. A printable version of
the PSRC form can be obtained by clicking the link
below
Provider
Services Requisition Change Request
Provider Service
Request (Pharmacy) (PSR) form
The
PPSR form is completed by providers requesting authorization for
pharmaceutical services to CRS patients. A printable version of the
PSR form can be obtained by clicking the link
below
Pharmacy
Authorization Request
- Last Updated on August 05 2007