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.
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 Document Date: 1/4/2019
Appointment of Representative Form Document Date: 1/3/2019
AzAHP Organization-Facility Application Document Date: 08/05/2021 NEW
AzAHP Practitioner Data Form Document Date: 08/16/2021 NEW
AzAHP Provider Roster template Document Date: 9/4/2019
Bariatric Surgery Monthly Summary Worksheet Document Date: 6/12/2018
Behavioral Health Referral Form Document Date: 6/13/2018
ECT Prior Authorization Request Form Document Date: 6/13/2018
Electronic Fund Transfer (EFT) Form Document Date: 06/28/2021
Electronic Remittance Advice (ERA) Form Document Date: 6/16/2021
External MCA Care Management Referral Form Document Date: 04/08/2021 NEW
Hospice Information for Part D Plans Document Date: 11/18/2019
Medicare Waiver of Liability Form Document Date: 6/19/2018
Mercy Care Advantage Remit Format for Check Form Document Date: 6/19/2018
Mercy Care Advantage Remit Format for EFT Form Document Date: 6/19/2018
Mercy Care Provider Web Portal Registration Form Document Date: 04/15/2021 UPDATED
Mercy Care Provider Web Portal Registration Form (Non-Par) Document Date: 04/15/2021 UPDATED
Missed Appointment Log Document Date: 8/13/2018
PCP Change Request Form Document Date: 8/29/2019
Prior Authorization: DME Request Form Dcument Date: 03/17/2022 UPDATED
Prior Authorization: Standard Request Form Document Date: 03/17/2022 UPDATED
Prior Authorization: Therapy and Home Health Request Form Document Date: 07/29/2022 Updated
Provider Assistance Program Form Document Date: 6/19/2018
Request for Psychological Testing Form Document Date: 6/19/2018
Resubmission Form Document Date: 01/12/2022
Skilled Stay Continued Authorization Request Form Document Date: 6/19/2018