Arizona Physicians' and Pharmaceutical Fee

Schedule Dental Rate Table Request Form

Instructions for Dental Rate Table Request Form

Stakeholders may complete a Dental Rate Table Request Form from the Medical Resource Office (MRO). Please download and complete the form in its entirety, and submit it via email to [email protected] or fax to 602.542.4797.

While the MRO Division cannot guarantee specific delivery dates, we process all requests sequentially in the order they are received. Please notify the MRO Division if you do not receive the Arizona Dental Fee Schedule Rate Table via email within two (2) business days of your request.

Please do not file a duplicate request, as this may delay the process.

IMPORTANT:

This form must be completed in its entirety, including the agreement to Terms & Conditions. The Terms & Conditions allow for the Dental Rate Table to be circulated within the organization upon receipt.