Provider Forms
Important provider forms
*** Important notice *** The EFT and ERA enrollment forms have changed. Enroll by downloading the paper forms.
Need help? For questions regarding the forms or to check on enrollment status, please contact Provider Relations at 602-263-3000, Express Service Code 631.
You can also send us a message via our website using the Contact Us form.
Whether you need to file a claim, inform us of a change of address or request prior authorization for a treatment, filling out the necessary forms will help us respond to your needs quickly and efficiently. Just click on the appropriate form name below to get started.
Annual Wellness Visit Provider Form PDF Opens In New Window Document Date: 06/13/2018
Appointment of Representative Form PDF Opens In New Window Document Date: 06/12/2018
AzAHP Facility Application PDF Opens In New Window Document Date: 06/12/2018
AzAHP Organizational Data Form PDF Opens In New Window Document Date: 06/12/2018
AzAHP Practitioner Data Form PDF Opens In New Window Document Date: 06/12/2018
AzAHP Provider Roster Template PDF Opens In New Window Document Date: 06/12/2018
Bariatric Surgery Monthly Summary Worksheet PDF Opens In New Window Document Date: 06/13/2018
Behavioral Health Referral Form PDF Opens In New Window Document Date: 06/13/2018
ECT Prior Authorization Request Form PDF Opens In New Window Document Date: 06/13/2018
Electronic Fund Transfer (EFT) Form PDF Opens In New Window Document Date: 06/13/2018
Electronic Remittance Advice (ERA) Form PDF Opens In New Window Document Date: 06/29/2018
Exclusive Prescriber Program Referral Form Document Date: 10/16/2018 NEW
Hospice Information for Part D Plans PDF Opens In New Window Document Date: 06/12/2018
Medical Case Management Referral Form PDF Opens In New Window Document Date: 06/19/2018
Medicare Waiver of Liability Form PDF Opens In New Window Document Date: 06/19/2018
Mercy Care Advantage Remit Format for Check Form PDF Opens In New Window Document Date: 06/19/2018
Mercy Care Advantage Remit Format for EFT Form PDF Opens In New Window Document Date: 06/19/2018
Mercy Care Web Portal Registration Form PDF Opens In New Window Document Date: 06/19/2018
PCP Change Request Form PDF Opens In New Window Docment Date: 06/19/2018
Prior Authorization: DME Request Form PDF Opens In New Window Document Date: 06/19/2018
Prior Authorization: Standard Request Form PDF Opens In New Window Document Date: 06/19/2018
Prior Authorization: Therapy and Home Health Request Form PDF Opens In New Window Document Date: 06/19/2018
Provider Assistance Program PDF Opens In New Window Document Date: 06/19/2018
Request for Psychological Testing PDF Opens In New Window Document Date: 06/19/2018
Resubmission Form PDF Opens In New Window Document Date: 06/19/2018
Skilled Stay Continued Authorization Request PDF Opens In New Window Document Date: 06/19/2018