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

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

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

AzAHP Practitioner Data Form Document Date:  08/16/2021 

AzAHP Provider Roster Template Document Date:  09/04/2019 

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

Commercial Oral Nutritional Supplements (EPSDT Members)  Document Date:  06/20/2018 

Complex Case Request Form Document Date:  06/12/2018 

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:  06/28/2021 

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 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 Notification of Adult BHRF & Adult BHTH Admission  Document Date:  12/08/2020 

Mercy Care Notification of Child & Adolescent BHIF, BHRT & TFC Admission  Document Date:  12/08/2020 

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:  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 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:  01/28/2020  

Prior Authorization Request Form Adult BHRF and ABHTH Document Date:  11/27/2020 

Prior Authorization Request Form 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:  06/12/2022  

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:  11/10/2021 

 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.