Important provider forms

*** Important notice *** The 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 click on the appropriate form name below to get started

AHCCCS Behavioral Health 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  

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:  04/13/2023  NEW PROCESS 

Electronic Remittance Advice (ERA) Form Document Date:  04/13/2023  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 

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 

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:  06/19/18  

Perinatal Referral Form ( Document Date: 03/03/2023  

Prior Authorization: Aetna Family Planning Service Request Form

Prior Authorization: Clinical Trials  Document Date:  05/01/2023

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

Prior Authorization:  SUD Residential Form Document Date:  04/18/2023 

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  Document Date:  06/25/2018

Request for Psychological Testing Document Date:  06/19/2018  

Resubmission Form Document Date:  06/12/2022  


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  


Provider network files

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