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Forms for each plan
Order a member handbook
Other form
AHCCCS Behavioral Health Clinical Chart Audit Tool: 3/7/2022 NEW
AzAHP Organization-Facility Application (PDF): 8/5/2021
AzAHP Practitioner Data Form (PDF): 8/16/2021
AzAHP Provider Roster Template: 9/4/2019
Bariatric Surgery Monthly Summary Worksheet (PDF): 6/20/2018
Commercial Oral Nutritional Supplements (EPSDT Members) (PDF): 6/20/2018
Complex Case Review Form (PDF): 6/20/2018
Consent to Sterilization (PDF): 6/12/2018
ECT Prior Authorization Request Form (PDF): 6/20/2018
EPSDT Clinical Sample Template (PDF): 2/2022
EPSDT Supply Order Form (PDF): 3/22/2022
Exclusive Prescriber Program Referral Form (PDF): 10/16/2018
External ACC Care Management Referral Form (PDF): 4/8/2021
Hysterectomy Consent Form (PDF): 6/12/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission (PDF): 12/8/2020
Mercy Care Notification of Child and Adolescent BHIF, BHRT & TFC Admission (PDF): 2/8/2020
Mercy Care Complete Care Remit Format for Check Form (PDF): 6/20/2018
Mercy Care Complete Care Remit Format for EFT Form (PDF): 6/20/2018
Mercy Care Provider Web Portal Registration Form (PDF): 4/15/2021
Mercy Care Provider Web Portal Registration Form (Non-Par) (PDF): 4/15/2021
Missed Appointment Log: 8/7/2018
Oral Nutritional Supplements (Members 21 Years of Age and Older) (PDF): 6/12/2018
PCP Change Request Form (PDF): 8/29/19
Perinatal Referral Form (PDF): 10/23/2019
Prior Authorization (PDF): Aetna Family Planning Service Request Form (PDF) 11/6/2015
Prior Authorization: DME Request Form (PDF): 3/17/2022 Updated
Prior Authorization Form for Substance Use Residential (PDF): 7/20/2021
Prior Authorization: Standard Request Form (PDF): 6/19/2018
Prior Authorization: Therapy and Home Health Request Form (PDF): 7/29/2022 Updated
Prior Authorization Request for ABA Services (PDF): 1/28/2020
Prior Authorization Request Form for Adult BHRF and ABHTH (PDF): 11/27/2020
Prior Authorization Request Form for Children and Adolescents BHIF, BHRF, HCTC (PDF): 6/19/2020
Provider Assistance Program (PDF) : 6/19/2018
Referral for Behavioral Health Services (PDF) 8/21/2009
Request for Psychological Testing (PDF): 6/19/2018
Resubmission Form (PDF): 1/12/2022
SA FPS Remit Format for Check Form (PDF)
SA FPS Remit Format for EFT Form (PDF)
Skilled Stay Continued Authorization Request (PDF): 6/19/2018
Specialist Referral Form (PDF): 6/26/2018
Subacute Detox Admission (PDF): 11/10/2021
Advanced Directives Resources (English) (PDF): 6/4/2018
Advanced Directives Resources (Spanish) (PDF): 6/4/2018
AETNA Family Planning Remit Format - Check (PDF): 6/4/2018
AETNA Family Planning Remit Format - EFT (PDF): 6/4/2018
AHCCCS Contracted Health Plans Behavioral Health Coordinators (PDF): 6/4/2018
Annual RBHA IHH/BHH Employment Related Training Attestation (PDF): 6/15/2022 NEW
Authorization Criteria Adult SMI Behavioral Health Residential Facility (PDF): 6/4/2018
Authorization Criteria for Behavioral Health Residential Facility Children/Adolescent (PDF): 6/4/2018
Care Management Referral Form (PDF): 1/28/2021 NEW
Collaborative Protocol with Adult Probation (PDF): 6/5/2018
Collaborative Protocol with Department of Child Safety (PDF): 6/5/2018
Collaborative Protocol with Maricopa County Juvenile Probation Department (PDF): 6/5/2018
Collaborative Protocol with Phoenix VA Health Care System (PVAHCS) (PDF): 6/5/2018
Collaborative Protocols 2021 Statewide AHCCCS and ADES-RSA (PDF): 12/22/2021 NEW
Collaborative Protocol with the Arizona Department of Corrections (PDF): 6/5/2018
Collaborative Protocol with Veterans Administration Health Care System (PDF): 11/7/2018
Crisis Intervention Services Delivered in Emergency Departments (PDF): 6/11/2018
Electroconvulsive Therapy (ECT) Medical Necessity Criteria (PDF): 6/11/2018
Mercy RBHA Remit Format for Check (PDF): 6/11/2018
Mercy RBHA Remit Format for EFT (PDF): 6/11/2018
Provider Course Equivalency (PDF): 6/11/2018
Provider Deliverables (PDF): 6/11/2018
Provider Deliverables Peer Support Specialist/Recovery Support Specialist Assignment Roster (PDF): 6/11/2018
Psychological and Neuropsychological Testing Medical Necessity Criteria (PDF): 6/11/2018
T/RBHA Acute Health Plan and Provider Coordinator Contact Information (PDF): 6/11/2018
Order a member handbook
Other forms
ACC Psych Rehab Report: 6/15/2022 NEW
ACC Psychiatric Rehabilitation Reporting Deliverable Attestation (PDF): 6/15/2022 NEW
ACT Exit Criteria Screening Tool Form (PDF): 6/13/2018
ACT-RBHA RSA/VR Referral Coordination Fom (PDF): 6/13/2018
ACT Team Residential/Flex Care/CLP with Outside ACT Supports Supplemental Form (PDF): 6/13/2018
ADCS 60 Day Review (PDF): 11/4/2019
ADCS Forms (PDF): 11/4/2019
ADCS Inpatient Assessment Report (PDF): 11/4/2019
ADCS Outpatient Assessment Report (PDF): 11/4/2019
ADCS Statement from Medical Director (PDF): 11/4/2019
Adult HCTC Application (PDF): 6/13/2018
Advanced Directive Form (English) (PDF): 6/13/2018
Advanced Directive Form (Spanish) (PDF): 6/13/2018
AHCCCS Behavioral Health Clinical Chart Audit Tool: 3/7/2022
AzAHP Organization-Facility Application (PDF): 8/5/2021
AzAHP Practitioner Data Form (PDF): 8/16/2021
AzAHP Provider Roster Template: 9/4/2019
Bed Hold or Therapeutic Leave Request for Level I RTC (PDF): 6/12/2018
Bridge to Permanency Housing Application (PDF): 6/20/2018
Business Continuity and Incident Management Plan Checklist (PDF): 6/20/2018
Certificate of Need (CON) (PDF): 10/2/2019
Child and Adolescent 45 Day Clinical Review for Continued Prior Residential Facility (PDF): 6/20/2018
Child and Adolescent 60 Day Clinical Review for Continued Stay Prior Authorization of HCTC (PDF)
Community Living Application (PDF): 6/20/2018
Complex Case Review Form (PDF): 6/20/2018
Consent for Assessment for Level of Care (English) (PDF): 6/20/2018
Consent for Assessment for Level of Care (Spanish) (PDF): 6/20/2018
Consent for Electroconvulsive Therapy (ECT) (PDF): 6/20/2018
Consent to Treatment (English) (PDF): 7/1/2018
Consent to Treatment (Arabic) (PDF): 6/10/2020
Consent to Sterilization - Attachment A (PDF): 6/8/2018
Crisis Response Network Forms (PDF): 6/11/2018
Demographic Form (PDF): 6/22/2018
DME Prior Authorization Standard Request Form (PDF): 6/22/2018
ECT Prior Authorization Request (PDF): 6/22/2018
EPSDT Clinical Sample Template: 2/2022
EPSDT Supply Order Form (PDF): 3/22/2022
Eviction, Move In and Utilities Request Form (PDF): 7/18/2022 NEW
External ACC Care Management Referral Form (PDF): 4/8/2020
Exclusive Prescriber Program Referral Form (PDF): 10/16/2018
Hotel Assistance Extension Request (PDF): 7/18/2022 NEW
Hotel Assistance Request (PDF): 7/18/2022 NEW
Hysterectomy Consent Form (PDF): 6/12/2018
Interagency PNO Client Transfer Form (PDF): 6/22/2018
Level II PASRR Psychiatric Evaluation (PDF): 6/22/2018
Member's PCP Change Request Form (PDF): 6/22/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission (PDF): 12/8/2020
Mercy Care Notification of Child & Adolescent BHIF, BHRT & TFC Admission (PDF): 12/8/2020
Mercy Care Web Portal Registration Form (PDF): 6/11/2021
Mercy Care Web Portal Registration Form (Non-Par) (PDF): 6/11/2021
Mercy Care RBHA SFTP Connectivity Form (PDF): 6/30/2022 NEW
Missed Appointment Log (PDF): 8/13/2018
Moving Assistance Request (PDF): 7/18/2022 NEW
Network Material Change Transition Grid Template (PDF): 6/22/2018
Oral Nutritional Supplements - Members 21 Years of Age and Older (PDF): 6/12/2018
Perinatal Form (PDF): 10/23/2019
PNO/Agency/Single POC Up (PDF)
Prior Authorization DME Request Form (PDF): 3/17/2022
Prior Authorization Form for Substance Use Residential (PDF): 7/20/2021
Prior Authorization Standard Request Form (PDF): 3/17/2022
Prior Authorization for Family Planning (PDF)
Prior Authorization for Inpatient Eating Disorder (PDF): 6/22/2018
Prior Authorization for Therapy and Home Health Request Form (PDF): 7/29/2022 Updated
Prior Authorization Request for ABA Services (PDF) : 1/28/2020
Prior Authorization Request for BHRF and ABHTH (PDF): 11/27/2020
Prior Authorization Request Form Children and Adolescents BHIF, BHRF, HCTC (PDF): 6/20/2020
Provider Assistance Program Form (PDF): 6/22/2018
Psychiatric Security Review Board/GEI Conditional Release Monthly Report (PDF): 6/12/2017
Psychiatric Visit Information Form (PDF): 6/22/2018
Psychological-Neuropsychological Testing Prior Authorization (PDF): 6/22/2018
RBHA and RSA/VR Referral Coordination Form (PDF): 6/12/2018
RBHA Psychiatric Rehabilitation Attestation (PDF): 6/14/2022
RBHA Psychiatric Rehabilitation Report: 6/14/2022
Re-Certification of Need (RON) (PDF): 6/25/2018
Recovia Referral Form (PDF): 6/25/2018
Request for Direct Support or Specialty Provider Services (PDF): 6/25/2018
Resubmission Form (PDF): 1/12/2022
Scattered Site Housing Application (PDF): 6/25/2018
Seclusion and Restraint Individual Reporting Form (PDF): 6/25/2018
Service Request Authorization: Family Planning Authorizations (PDF)
Skilled Nursing Facility Continued Authorization Request (PDF): 6/25/2018
SMI Assessment Packet Checklist (PDF): 6/26/2018
Specialist Referral Form (PDF): 6/26/2018
Special Treatment Plan for Forced Administration of Medications (PDF): 10/12/2020
Subacute Detox Admission Form (PDF): 11/10/2021
Supervisory Care Home Monthly Progress Report (PDF): 6/26/2018
Therapy & Home Health Prior Authorization Request Form (PDF): 6/26/2018
Timely Filing Waiver Request Form (PDF): 1/18/2019
Transitional Living and Planning Application (PDF): 6/13/2018
Twenty-One Day Service Tracking Bi-Monthly Report With Instructions (PDF): 6/26/2018
VI-SPDA (PDF) 4/30/18
Vocational Activity Profile Form -RS Only (English) (PDF): 6/7/2019
Vocational Activity Profile Form -RS Only (Spanish) (PDF): 6/7/2019
Waiver of 3 Day SMI Eligibility Determination (English) (PDF): 6/26/2018
Waiver of 3 Day SMI Eligibility Determination (Spanish) (PDF): 6/26/2018
AHCCCS Behavioral Health Clinical Chart Audit Tool: 3/7/2022 NEW
AzAHP Organizational-Facility Application (PDF): 8/5/2021
AzAHP Practitioner Data Form (PDF): 8/16/2021
Bariatric Surgery Monthly Summary Worksheet (PDF): 6/20/2018
Commercial Oral Nutritional Supplements (EPSDT Members) (PDF): 6/20/2018
Complex Case Review Form (PDF): 6/20/2018
Consent to Sterilization (PDF): 6/12/2018
ECT Prior Authorization Request Form (PDF): 4/9/2021
EPSDT Clinical Sample Template: 2/2022
EPSDT Supply Order Form (PDF): 3/22/2022
Exclusive Prescriber Program Referral Form (PDF): 10/16/2018
External DCS CHP Care Management Referral Form (PDF): 4/8/2021
Hysterectomy Consent Form (PDF): 6/12/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission (PDF): 12/8/2020
Mercy Care Notification of Child and Adolescent BHIF, BHRT & TFC Admission (PDF): 12/8/2020
Mercy Care Complete Care Remit Format for Check Form (PDF): 6/20/2018
Mercy Care Complete Care Remit Format for EFT Form (PDF): 6/20/2018
Mercy Care Provider Web Portal Registration Form (PDF): 4/15/2021
Mercy Care Provider Web Portal Registration Form (Non-Par) (PDF): 4/15/2021
Missed Appointment Log (PDF): 8/7/2018
Oral Nutritional Supplements (Members 21 Years of Age and Older) (PDF): 6/12/2018
PCP Change Request Form (PDF): 8/29/2019
Perinatal Referral Form (PDF): 10/23/2019
Prior Authorization: Clinical Trials: 5/1/2023
Prior Authorization DME Request Form (PDF): 3/17/2022 UPDATED
Prior Authorization Form for Substance Use Residential (PDF): 7/20/2021
Prior Authorization Standard Request Form (PDF): 3/17/2022 UPDATED
Prior Authorization Therapy and Home Health Request Form (PDF): 7/29/2022 UPDATED
Prior Authorization Request for ABA Services (PDF): 4/9/2021
Prior Authorization Request Form for Adult BHRF and ABHTH (PDF): 11/27/2020
Prior Authorization Request Form for Children and Adolescents BHIF, BHRF, HCTC (PDF): 6/19/2020
Prior Authorization Request Form for Substance Use Residential (PDF): 7/20/2021
Provider Assistance Program (PDF): 6/19/2018
Referral for Behavioral Health Services (PDF)
Request for Psychological Testing (PDF): 6/19/2018
Resubmission Form (PDF): 6/19/2018
SA FPS Remit Format for Check Form (PDF)
SA FPS Remit Format for EFT Form (PDF)
Skilled Stay Continued Authorization Request (PDF):6/19/2018
Specialist Referral Form (PDF): 6/26/2018
Provider network files
You have access to our Mercy Care DCS CHP Provider Directory (May 2022) JSON files. You can download them to review data.
AHCCCS Behavioral Health Clinical Chart Audit Tool: 3/7/2022 NEW
AzAHP Organization-Facility Application (PDF): 8/5/2021 NEW
AzAHP Practitioner Data Form (PDF): 8/16/2021 NEW
AzAHP Provider Roster Template: 9/4/2019
Bariatric Surgery Monthly Summary Worksheet (PDF): 6/20/2018
Care Management Referral Form (PDF): 1/28/2021 NEW
Commercial Oral Nutritional Supplements (EPSDT Members) (PDF):6/20/2018
Complex Case Review Form (PDF): 6/12/2018
Consent to Sterilization (PDF): 6/12/2018
ECT Prior Authorization Request Form (PDF):6/20/2018
EPSDT Clinical Sample Template: 2/2022
EPSDT Supply Order Form (PDF): 3/22/2022
Exclusive Prescriber Program Referral Form (PDF): 10/16/2018
Hysterectomy Consent Form (PDF): 6/12/2018
Mercy Care Complete Care Remit Format for Check Form (PDF): 6/20/2018
Mercy Care Complete Care Remit Format for EFT Form (PDF): 6/20/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission (PDF): 12/0/2020 NEW
Mercy Care Notification of Child and Adolescent BHIF, BHRF & TFC Admission (PDF): 12/0/2020 NEW
Mercy Care Provider Web Portal Registration Form (PDF): 4/15/2021 UPDATED
Mercy Care Provider Web Portal Registration Form (Non-Par) (PDF): 4/15/2021 UPDATED
Missed Appointment Log (PDF): 8/13/2018
Oral Nutritional Supplements (Members 21 Years of Age and Older) (PDF): 6/12/2018
PCP Change Request Form (PDF): 6/19/18
Perinatal Referral Fomr (PDF): 6/20/2018
Prior Authorization: DME Request Form (PDF): 7/20/2021 NEW
Prior Authorization Form for Substance Use Residential (PDF): 3/17/2022 UPDATED
Prior Authorization: Standard Request Form (PDF): 7/29/2022 UPDATED
Prior Authorization: Therapy and Home Health Request Form (PDF): 1/28/2020
Prior Authorization Request for ABA Services (PDF)
Prior Authorization Request Form Adult BHRF and ABHTH (PDF): 11/27/2020 UPDATED
Prior Authorization Request Form Children and Adolescents BHIF, BHRT, HCTC (PDF): 6/19/2020
Provider Assistance Program (PDF): 6/19/2018
Referral for Behavioral Health Services (PDF)
Request for Psychological Testing (PDF): 6/19/2018
Resubmission Form (PDF): 1/12/2022
SA FPS Remit Format for Check Form (PDF)
SA FPS Remit Format for EFT Form (PDF)
Skilled Stay Continued Authorization Request (PDF):6/19/2018
Specialist Referral Form (PDF):6/26/2018
Subacute Detox Admission Form (PDF): 11/10/2021 NEW
AHCCCS Behavioral Health Chart Audit Tool: 3/7/2022 NEW
AzAHP Organization-Facility Application (PDF): 8/5/2021 NEW
AzAHP Practitioner Data Form (PDF): 8/16/2021 NEW
AzAHP Provider Roster Template: 9/4/2019
Bariatric Surgery Monthly Summary Worksheet (PDF): 6/20/2018
Commercial Oral Nutritional Supplements (EPSDT Members) (PDF): 6/20/2018
Complex Case Request Form (PDF): 6/12/2018
Consent to Sterilization (PDF): 6/12/2018
ECT Prior Authorization Request Form (PDF): 6/20/2018
EPSDT Clinical Sample Template: 2/2022
EPSDT Supply Order Form (PDF): 3/22/2022
Exclusive Prescriber Program Referral Form (PDF): /16/2018
External ACC Care Management Referral Form (PDF): 4/8/2021 NEW
Hysterectomy Consent Form (PDF): 6/12/2018
Mercy Care Complete Care Remit Format for Check Form (PDF): 6/20/2018
Mercy Care Complete Care Remit Format for EFT Form (PDF): 6/20/2018
Mercy Care Notification of Adult BHRF & Adult BHTH Admission (PDF): 12/0/2020 NEW
Mercy Care Notification of Child & Adolescent BHIF, BHRT & TFC Admission (PDF): 12/0/2020 NEW
Mercy Care Provider Web Portal Registration Form (PDF): 4/15/2021 UPDATED
Mercy Care Provider Web Portal Registration Form (Non-Par) (PDF): 4/15/2021 UPDATED
Missed Appointment Log (PDF): 8/7/2018
Oral Nutritional Supplements (Members 21 Years of Age and Older) (PDF): 6/12/2018
PCP Change Request Form (PDF): 6/19/18
Perinatal Referral Form (PDF): 6/20/2018
Prior Authorization: Aetna Family Planning Service Request Form (PDF)
Prior Authorization: DME Request Form (PDF): 6/19/2018
Prior Authorization Form for Substance Use Residential (PDF): 7/20/2021 NEW
Prior Authorization: Standard Request Form (PDF): 3/17/2022 UPDATED
Prior Authorization: Therapy and Home Health Request Form (PDF): 7/29/2022 Updated
Prior Authorization Request for ABA Services (PDF): 1/28/2020
Prior Authorization Request Form Adult BHRF and ABHTH (PDF): 11/27/2020 UPDATED
Prior Authorization Request Form Children and Adolescents BHIF, BHRF, HCTC (PDF): 6/19/2020
Provider Assistance Program (PDF): 6/19/2018
Referral for Behavioral Health Services (PDF)
Request for Psychological Testing (PDF): 6/19/2018
Resubmission Form (PDF): 6/12/2022
SA FPS Remit Format for Check Form (PDF)
SA FPS Remit Format for EFT Form (PDF)
Skilled Stay Continued Authorization Request (PDF): 6/19/2018
Specialist Referral Form (PDF): 6/26/2018
Subacute Detox Admission Form (PDF): 11/10/2021 NEW
Annual Wellness Visit Provider Form (PDF): 1/4/2019
Appointment of Representative Form (PDF): 1/3/2019
AzAHP Organization-Facility Application (PDF): 8/5/2021 NEW
AzAHP Practitioner Data Form (PDF): 8/16/2021 NEW
AzAHP Provider Roster template: 9/4/2019
Bariatric Surgery Monthly Summary Worksheet (PDF): 6/12/2018
Behavioral Health Referral Form (PDF): 6/13/2018
ECT Prior Authorization Request Form (PDF): 6/13/2018
External MCA Care Management Referral Form (PDF): 4/8/2021 NEW
Hospice Information for Part D Plans (PDF): 11/18/2019
Medicare Waiver of Liability Form (PDF): 6/19/2018
Mercy Care Advantage Remit Format for Check Form (PDF): 6/19/2018
Mercy Care Advantage Remit Format for EFT Form (PDF): 6/19/2018
Mercy Care Provider Web Portal Registration Form (PDF): 4/15/2021 UPD
Mercy Care Provider Web Portal Registration Form (Non-Par) (PDF): 4/15/2021 UPD
Missed Appointment Log (PDF): 8/13/2018
PCP Change Request Form (PDF): 8/29/2019
Prior Authorization: DME Request Form (PDF): 3/17/2022 UPD
Prior Authorization: Standard Request Form (PDF): 3/17/2022 UPD
Prior Authorization: Therapy and Home Health Request Form (PDF): 7/29/2022 Upd
Provider Assistance Program Form (PDF): 6/19/2018
Request for Psychological Testing Form (PDF): 6/19/2018
Resubmission Form (PDF): 1/12/2022
Skilled Stay Continued Authorization Request Form (PDF): 6/19/2018