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Provider forms

Need to file a claim, tell us about your change of address or request prior authorization for a treatment? Just complete the right form. Then, we can respond to your needs quickly and efficiently. Be sure you check back here for updates. We update the forms regularly to improve your experience.

 

Forms for each plan

Order a member handbook

Member handbook order form
 

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 for Coordination of Care with UnitedHealthcare's Children's Rehabilitative Services (CRS) Programs (PDF): 6/5/2018

Collaborative Protocol with Department of Child Safety (PDF): 6/5/2018 

Collaborative Protocol with Department of Economic Security/Division of Developmental Disabilities (DES/DDD) - Child and Adult (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

Member handbook order form

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

Questions?

Check your provider manual for answers. Or contact us.