Member Forms
Looking for a Mercy Care Advantage form? You can download any of the forms below at no cost.
If you have any questions, call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711), 8:00 a.m. - 8:00 p.m., 7 days a week for more information.
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Forms
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- Appointment of Representative Form (English | Español)
- Coverage Determination Form (Print | Online)
- Coverage Redetermination Request Form (Print | Online)
- Enrollment Form (English | Español)
- Enrollment Form Instructions (English | Español)
- Medicare Part D Prescription Claim Form (English | Español)
- Personal Medication List
- Prescription Drug Mail-Order Form (English | Español)
- Patient Checklist (English | Español)
- Removal of Authorization Previously Given to Mercy Care (English | Español)
- Request for an Accounting of Disclosures of Protected Health Information (PHI)
(English | Español) - Protected Health Information (PHI) Access Request (English | Español)
- Authorization to Release Psychotherapy Notes (English | Español)
- Authorization to Release Protected Health Information (PHI) (English | Español)
H5580_20_010
Last Updated: 12/10/2019