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

MCA Part B Drug Prior Auth or Step Therapy Exception Request  Document Date:  12/15/2020  NEW

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 Document Date: 6/19/2018

Prior Authorization: Standard Request Form Document Date: 6/19/2018

Prior Authorization: Therapy and Home Health Request Form Document Date: 11/13/2020 Updated

Provider Assistance Program Form Document Date: 6/19/2018

Request for Psychological Testing Form Document Date: 6/19/2018

Resubmission Form Document Date: 6/19/2018

Skilled Stay Continued Authorization Request Form Document Date: 6/19/2018