Provider Forms

*** Important notice *** The EFT and ERA enrollment process has changed. 

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 Non-Delegated Roster Document Date:  03/07/2023

AzAHP Organization-Facility Application Document Date: 08/05/2021 

AzAHP Practitioner Data Form Document Date:  08/05/2021

AzAHP Practitioner Practice Change Form Document Date: 03/07/2023  

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: 04/13/2023  NEW PROCESS

Electronic Remittance Advice (ERA) Form Document Date: 04/13/23 NEW PROCESS

External MCA Care Management Referral Form  Document Date:  04/08/2021  

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 

Mercy Care Provider Web Portal Registration Form (Non-Par) Document Date: 04/15/2021 

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  

Prior Authorization: Standard Request Form Document Date: 03/17/2022  

Prior Authorization: Therapy and Home Health Request Form  Document Date: 07/29/2022 

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