Provider Forms

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

AHCCCS Behavioral Health Clinical Chart Audit Tool Document Date:  03/07/2022  

AzAHP Non-Delegated Roster  Document Date:  03/07/2023

AzAHP Organization-Facility Application Document Date:  08/05/2021  

AzAHP Practitioner Data Form Document Date:  08/05/2021

AzAHP Practitioner Practice Change Form Document Date:  03/07/2023  

Bariatric Surgery Monthly Summary Worksheet   Document Date:  06/20/2018  

Care Management Referral Form Document Date: 08/2022  

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:  06/20/2018  

Electronic Funds Transfer (EFT) Form Document Date:  03/17/2023  NEW PROCESS  

Electronic Remittance Advice (ERA) Form Document Date:  03/17/2023  NEW PROCESS    

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 

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 

Notification of Subacute Detox Admission Document Date:  11/22/2022

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:  03/03/2023  

Prior Authorization: Aetna Family Planning Service Request Form

Prior Authorization: Clinical trials

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: 06/19/2018    

Prior Authorization: Therapy and Home Health Request Form  Document Date:  07/29/2022 

Prior Authorization Request for ABA Services Document Date:  01/28/2020  

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  

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:  01/12/2022  

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

Subacute Detox Admission Form Date: 11/15/2022  


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. 


Provider network files

This link provides our Complete Care/Developmental Disabilities provider directory JSON file which can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.