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 Practice Change Form
Bariatric Surgery Monthly Summary Worksheet PDF
Behavioral Health Service Referral Form PDF
Commercial Oral Nutritional Supplements (EPSDT Members)
ECT Prior Authorization Request Form
Electronic Funds Transfer (EFT) Form
Electronic Remittance Advice (ERA) Form
EPSDT Clinical Sample Template
Exclusive Prescriber Program Referral 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)
Notification of Subacute Detox Admission
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
Request for Psychological Testing
Skilled Stay Continued Authorization Request