Example of a single case agreement 2026

1. Click ‘Get Form’ to open the Outpatient Behavioral Health Non-Par Provider Single Case Agreement Request Form in our editor.
2. Begin by filling in the urgent request section if applicable, noting the date and member details such as name and AHCCCS ID number.
3. Complete the Clinical Team information section with your provider organization, address, TIN, NPI, and contact details for the clinical team lead.
4. Describe the current gap in the system that necessitates this Single Case Agreement. Be specific about the clinical needs.
5. In the servicing provider/facility information section, provide all relevant details about the servicing provider organization including their TIN and NPI.
6. Select the type of request you are making—either a new Single Case Agreement or an extension/addition to an existing one—and complete the corresponding sections.
7. Detail treatment goals and check reasons for requesting out-of-network services. Include primary and additional diagnoses along with CPT/HCPCT codes.
8. Finally, ensure all fields are filled accurately before submitting to prevent delays. Attach any necessary documentation to support your request.

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