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