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 Document Date: 03/07/2022
AzAHP Organizational-Facility Application Document Date: 08/05/2021
AzAHP Practitioner Data Form Document Date: 08/16/2021
Bariatric Surgery Monthly Summary Worksheet Document Date: 06/20/2018
Commercial Oral Nutritional Supplements (EPSDT Members) Document Date: 06/20/2018
Complex Case Review Form Document Date: 06/20/2018
Consent to Sterilization Document Date: 06/12/2018
ECT Prior Authorization Request Form Document Date: 04/09/2021
Electronic Funds Transfer (EFT) Form Document Date: 06/28/2020
Electronic Remittance Advice (ERA) Form Document Date: 06/16/2021
EPSDT Clinical Sample Template Document Date: 02/2022
EPSDT Supply Order Form Document Date: 03/22/2022
Exclusive Prescriber Program Referral Form Document Date: 10/16/2018
Care Management Referral Form Document Date: 08/2022
Hysterectomy Consent Form Document Date: 06/12/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission Document Date: 12/08/2020
Mercy Care Notification of Child and Adolescent BHIF, BHRT & TFC Admission Document Date: 12/08/2020
Mercy Care Complete Care Remit Format for Check Form Document Date: 06/20/2018
Mercy Care Complete Care Remit Format for EFT Form Document Date: 06/20/2018
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: 08/07/2018
Oral Nutritional Supplements (Members 21 Years of Age and Older) Document Date: 06/12/2018
PCP Change Request Form Document Date: 08/29/19
Perinatal Referral Form Document Date: 10/23/2019
Prior Authorization: Aetna Family Planning Service Request Form
Prior Authorization: DME Request Form Document Date: 03/17/2022
Prior Authorization Form for Substance Use Residential Document Date: 07/20/2021
Prior Authorization: Standard Request Form Document Date: 03/17/2022
Prior Authorization: Therapy and Home Health Request Form Document Date: 07/29/2022
Prior Authorization Request for ABA Services Document Date: 04/09/2021
Prior Authorization Request Form for Adult BHRF and ABHTH Document Date: 11/27/2020
Prior Authorization Request Form for Children and Adolescents BHIF, BHRF, HCTC Document Date: 06/19/2020
Prior Authorization Request Form for Substance Use Residential Document Date: 07/20/2021
Provider Assistance Program Document Date: 06/19/2018
Referral for Behavioral Health Services
Request for Psychological Testing Document Date: 06/19/2018
Resubmission Form Document Date: 06/19/2018
SA FPS Remit Format for Check Form
SA FPS Remit Format for EFT Form
Skilled Stay Continued Authorization Request Document Date: 06/19/2018
Specialist Referral Form Date: 06/26/2018
Electronic Funds Transfer
Sign up to receive funds electronically
Mercy Care offers electronic funds payment directly to your bank account for your convenience. If you are interested in this payment option, download the Electronic Funds Transfer (EFT) Form. Complete the EFT Form in its entirety (including two authorized signatures), and fax it along with a voided check or a formal letter from your banking institution for verification of your bank account number to:
Mercy Care
Attn: Mercy Care Finance EFT Enrollment
Fax: 1-866-237-0760
Please Note: Aetna EFT forms WILL NOT be accepted.