Provider Forms

*** Important notice *** ERA and EFT 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 cick on the appropriate form name below to get started

AHCCCS Behavioral Health Clinical Chart Audit Tool   

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

AzAHP Organization-Facility Application   

AzAHP Practitioner Data Form

AzAHP Practitioner Practice Change Form  

Bariatric Surgery Monthly Summary Worksheet PDF  

Behavioral Health Service Referral Form PDF 

Care Management Referral Form  

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 

Fitbit Request 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

Oral Nutritional Supplements (Members 21 Years of Age and Older)

PCP Change Request Form

Perinatal Referral Form

Prior Authorization: Aetna Family Planning Service Request Form

Prior Authorization: Clinical Trials

Prior Authorization: DME Request Form

Prior Authorization:  SUD Residential 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

SA FPS Remit Format for Check Form

SA FPS Remit Format for EFT Form

SFTP Request Form

Skilled Stay Continued Authorization Request 

Specialist Referral Form

Subacute Detox Admission Form

Traditional Healing Request Form

 

 

JSON - Mercy Care CC/DD Provider Directory