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 click on the appropriate form name below to get started

AzAHP Facility Application  Document Date:  06/12/2018  

AzAHP Organizational Data Form  Document Date:  06/12/2018  

AzAHP Practitioner Data Form   Document Date:  06/12/2018  

AzAHP Provider Roster Template  Document Date:  06/12/2018  

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

Commercial Oral Nutritional Supplements (EPSDT Members)  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:  01/11/2019  

Electronic Remittance Advice (ERA) Form  Document Date:  06/29/2018    

EPSDT Standards and Tracking Forms  Document Date:  06/12/2018  

EPSDT Supply Order Form  Document Date:  06/20/2018  

Exclusive Prescriber Program Referral Form Document Date:  10/16/2018  NEW

Hysterectomy Consent Form  Document Date:  06/12/2018     

Medical Case Management Referral Form  Document Date:  06/19/2018  

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 Web Portal Registration Form  Document Date:  06/19/2018  

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:  06/19/18  

Perinatal Referral Form  Document Date:  06/20/2018  

Prior Authorization: Aetna Family Planning Service Request Form

Prior Authorization: DME Request Form  Document Date:  06/19/2018    

Prior Authorization: Standard Request Form  Document Date:  06/19/2018    

Prior Authorization: Therapy and Home Health Request Form  Document Date:  06/19/2018  

Provider Assistance Program  Document Date:  06/19/2018  

Referral for Behavioral Health Services (PDF) 

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  

Synagis (palivizumab) Authorization Form 2018-2019 season Document Date:  10/08/2018  NEW  

 

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 Enrollment (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: MCP Finance EFT Enrollment

Fax: 1-860-262-7645