Forms

Important provider 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.

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

AzAHP Facility Application Document Date:  01/01/2019 

AzAHP Organizational Data Form  Document Date:  01/01/2019 

AzAHP Practitioner Data Form Document Date:  01/01/2019

AzAHP Provider Roster Template Document Date:  06/12/2018 

Bariatric Surgery Monthly Summary Worksheet  Document Date:  06/20/2018 

Commercial Oral Nutritional Supplements (EPSDT Members)  Document Date:  06/20/2018 

Complex Case Review 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)  Document Date:  06/29/2018 

EPSDT Standards and Tracking Forms Document Date:  03/15/2019 NEW

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

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

Hysterectomy Consent Form  Document Date:  06/12/2018     

Medical Case Management Referral Form  Document Date:  06/19/2018 

Mercy Care Behavioral Health Prior Authorization Request Document Date:  05/16/2019  NEW

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:  07/10/2019  NEW 

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:  06/06/2019  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 Form Adult BHRF Date:  04/26/2019

Prior Authorization Request Form Children and Adolescents BHIF, BHRT, 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 

Synagis (palivizumab) Authorization Form 2018-20198 Season  Document Date:  10/08/2018  NEW