Forms

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.

You can also send us a message via our website using the Contact Us form.

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 Clinical Chart Audit Tool  

AzAHP Non-Delegated Roster (Please scroll to the bottom of the AzAHP web page to access this roster.)  

AzAHP Organization-Facility Application    

AzAHP Practitioner Data Form

AzAHP Practitioner Practice Change Form 

Bariatric Surgery Monthly Summary Worksheet PDF   

Behavioral Health Service Referral Form PDF 

Care Management Referral Form 

Commercial Oral Nutritional Supplements (EPSDT Members)  

Complex Case Review Form PDF 

Consent to Sterilization  

ECT Prior Authorization Request Form 

Electronic Funds Transfer (EFT) Form 

Electronic Remittance Advice (ERA) Form

EPSDT Clinical Sample Template

EPSDT Supply Order Form 

Exclusive Prescriber Program Referral Form

Hysterectomy Consent Form 

Mercy Care Medicaid Remit Format for Check Form 

Mercy Care Medicaid Remit Format for EFT Form 

Mercy Care Notification of Adult BHRF & Adult BHTH Admission

Mercy Care Notification of Child and Adolescent BHIF, BHRF & TFC Admission

Mercy Care Provider Financial Guide  (Document)

Attachment A - Quarterly Certification Statement (.csv)

Attachment B - Statement of Financial Position (.csv)

Attachment C - Mercy Care Disclosures Statement (.csv)

Attachment D - Mercy Care Statement of Activities (.csv)

Attachment E - Statement of Cash Flows (.csv)

Attachment F - Financial Ratio Analysis Comparison (.csv)

Attachment G - Conflict of Interest Disclosure (.csv)

Attachment H - Agency Cost Allocation Plan (.csv)

Attachment I - Provider Financial Reporting Request for Extension (.csv)

Attachment J - SABG and MHBG Funding and Expenses (.csv)

Attachment K - Fee Schedule Exception Template (.csv)

Mercy Care Provider Web Portal Registration Form

Mercy Care Provider Web Portal Registration Form (Non-Par)

Missed Appointment Log 

Notification of Subacute Detox Admission

Oral Nutritional Supplements (Members 21 Years of Age and Older) AHCCCS 310-GG Attachment A

PCP Change Request Form

Perinatal Referral Form

Prior Authorization: Clinical Trials

Prior Authorization: DME Request Form

Prior Authorization: Standard Request Form

Prior Authorization: Therapy and Home Health Request Form

Prior Authorization Request for ABA Services  

Prior Authorization Request Form Adult BHRF and ABHTH

Prior Authorization Request Form Children and Adolescents BHIF, BHRT, HCTC  

Provider Assistance Program

Request for Psychological Testing

Resubmission Form

Skilled Stay Continued Authorization Request

Specialist Referral Form

Subacute Detox Admission Form

Traditional Healing Request Form

JSON - Mercy Care LTC Provider Directory