Provider Forms

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.

Need help? For questions regarding the forms or to check on enrollment status, please contact Provider Relations at 602-263-3000.

AHCCCS Behavioral Health Clinical Chart Audit Tool   

AzAHP Non-Delegated Roster (Please scroll to the bottom of the AzAHP web page under Credentialing Forms to access this roster.)

AzAHP Organizational-Facility Application  

AzAHP Practitioner Data Form

AzAHP Practitioner Practice Change Form 

Bariatric Surgery Monthly Summary Worksheet PDF 

Behavioral Health Service Referral Form PDF  

Commercial Oral Nutritional Supplements (EPSDT Members)  

Complex Case Review Form PDF 

Consent to Sterilization   

ECT Prior Authorization Request Form 

Electronic Funds Transfer (EFT) Form 

Electronic Remittance Advice (ERA) Form 

EPSDT Clinical Sample Template

EPSDT Supply Order Form   

Exclusive Prescriber Program Referral Form  

Care Management Referral Form

Hysterectomy Consent Form

Mercy Care Notification of Adult BHRF & Adult BHTH Admission 

Mercy Care Notification of Child and Adolescent BHIF, BHRT & TFC Admission

Mercy Care Medicaid Remit Format for Check Form  

Mercy Care Medicaid Remit Format for EFT Form  

Mercy Care Provider Financial Guide  (Document)

Attachment A - Quarterly Certification Statement (.csv)

Attachment B - Statement of Financial Position (.csv)

Attachment C - Mercy Care Disclosures Statement (.csv)

Attachment D - Mercy Care Statement of Activities (.csv)

Attachment E - Statement of Cash Flows (.csv)

Attachment F - Financial Ratio Analysis Comparison (.csv)

Attachment G - Conflict of Interest Disclosure (.csv)

Attachment H - Agency Cost Allocation Plan (.csv)

Attachment I - Provider Financial Reporting Request for Extension (.csv)

Attachment J - SABG and MHBG Funding and Expenses (.csv)

Attachment K - Fee Schedule Exception Template (.csv)

Mercy Care Provider Web Portal Registration Form

Mercy Care Provider Web Portal Registration Form (Non-Par)

Missed Appointment Log

Notification of Subacute Detox Admission

PCP Change Request Form

Perinatal Referral Form 

Prior Authorization: Clinical Trials

Prior Authorization: DME Request Form

Prior Authorization: Standard Request Form

Prior Authorization: Therapy and Home Health Request Form

Prior Authorization Request for ABA Services   

Prior Authorization Request Form for Adult BHRF and ABHTH

Prior Authorization Request Form for Children and Adolescents BHIF, BHRF, HCTC

Provider Assistance Program 

Request for Psychological Testing

Resubmission Form

SFTP Request Form

Skilled Stay Continued Authorization Request 

Specialist Referral Form

Subacute Detox Admission Form

 

 

JSON - Mercy Care DCS CHP Provider Directory