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:  02/03/2020  NEW  

AzAHP Organizational Data Form Document Date:  02/03/2020  NEW

AzAHP Practitioner Data Form Document Date:  02/03/2020  NEW  

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:  01/11/2019  

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

EPSDT Standards and Tracking Forms Document Date:  05/16/2019  

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

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

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:  07/31/2019  

Mercy Care Web Portal Registration Form (Non-Par) Document Date:  11/11/2019 

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: GMH/SU Residential Substance Use Document Date:  02/11/2020  NEW 

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

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

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

Prior Authorization Request Form Adult BHRF Date:  04/26/2019

Prior Authorization Request Form Children and Adolescents BHIF, BHRF, HCTC Date:  04/26/2019

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.