Provider Forms

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. Please remember to submit EFT and ERA forms via secure e-mail or fax – do not mail EFT and ERA forms.

Provider Manual Forms and Attachments

Mercy Care RBHA Provider Manual Attachments

Advanced Directives Resources (English)   Document Date:  06/04/2018 

Advanced Directives Resources (Spanish)   Document Date:  06/04/2018 

AETNA Family Planning Remit Format - Check   Document Date:  06/04/2018 

AETNA Family Planning Remit Format - EFT   Document Date:  06/04/2018 

AHCCCS Contracted Health Plans Behavioral Health Coordinators   Document Date:  06/04/2018 

Authorization Criteria Adult SMI Behavioral Health Residential Facility   Document Date:  06/04/2018 

Authorization Criteria for Behavioral Health Residential Facility Children/Adolescent Document Date:  06/04/2018 

Authorization Criteria for Home Care Training for the Home Care Client (HCTC) Children/Adolescent Document Date:  06/04/2018 

Collaborative Protocol with Adult Probation Document Date:  06/05/2018 

Collaborative Protocol for Coordination of Care with UnitedHealthcare's Children's Rehabilitative Services (CRS) Programs Document Date:  06/05/2018   

Collaborative Protocol with Department of Child Safety Document Date:  06/05/2018   

Collaborative Protocol with Department of Economic Security/Division of Developmental Disabilities (DES/DDD) - Child and Adult  Document Date:  06/05/2018 

Collaborative Protocol with Maricopa County Juvenile Probation Department Document Date:  06/05/2018   

Collaborative Protocol with Phoenix VA Health Care System (PVAHCS)   Document Date:  06/05/2018 

Collaborative Protocols with RSA District I   Document Date:  06/05/2018 

Collaborative Protocol with the Arizona Department of Corrections Document Date:  06/05/2018  

Collaborative Protocol with Veterans Administration Health Care System  Document Date:  11/07/2018  NEW 

Crisis Intervention Services Delivered in Emergency Departments Document Date:  06/11/2018 

Electroconvulsive Therapy (ECT) Medical Necessity Criteria Document Date:  06/11/2018 

Mercy Maricopa Remit Format for Check Document Date:  06/11/2018 

Mercy Maricopa Remit Format for EFT Document Date:  06/11/2018 

Provider Course Equivalency Document Date:  06/11/2018 

Provider Deliverables Document Date:  06/11/2018 

Provider Deliverables Peer Support Specialist/Recovery Support Specialist Assignment Roster Document Date:  06/11/2018 

Psychological and Neuropsychological Testing Medical Necessity Criteria Document Date:  06/11/2018 

T/RBHA Acute Health Plan and Provider Coordinator Contact Information Document Date:  06/11/2018 

ACT Exit Criteria Screening Tool Form Document Date:  06/13/2018 

ACT-RBHA RSA/VR Referral Coordination Form  Document Date:  06/13/2018 

ACT Team Residential/Flex Care/CLP with Outside ACT Supports Supplemental Form   Document Date:  06/13/2018 

Adult HCTC Application Document Date:  06/13/2018 

Advanced Directive Form (English) Document Date:  06/13/2018 

Advanced Directive Form (Spanish) Document Date:  06/13/2018 

AzAHP Facility Credentialing and Recredentialing 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 

Bed Bugs Treatment Process Checklist Document Date:  06/12/2018   

Bed Bugs Treatment Service Ticket  Document Date:  06/12/2018   

Bed Hold or Therapeutic Leave Request for Level I RTC   Document Date:  06/12/2018 

Biohazard Cleaning Request Document Date:  06/12/2018 

Bridge to Permanency Housing Application Document Date:  06/20/2018 

Business Continuity and Incident Management Plan Checklist   Document Date:  06/20/2018 

Certificate of Need (CON)  Document Date:  10/03/2018  NEW

Child and Adolescent 45 Day Clinical Review for Continued Prior Residential Facility Document Date:  06/20/2018 

Child and Adolescent 60 Day Clinical Review for Continued Stay Prior Authorization of HCTC   DocDate;  06/20/2018

Community Living Application Document Date:  06/20/2018 

Complex Case Review Form  Document Date:  06/20/2018 

Consent for Assessment for Level of Care (English) Document Date:  06/20/2018 

Consent for Assessment for Level of Care (Spanish) Document Date:  06/20/2018 

Consent for Electroconvulsive Therapy (ECT) Document Date:  06/20/2018 

Consent to Release Protected Health Information (PHI) (English) Document Date:  06/22/2018 

Consent to Release Protected Health Information (PHI) (Spanish) Document Date:  06/22/2018 

Consent to Sterilization - Attachment A   Document Date:  06/08/2018 

Crisis Response Network Forms   Document Date:  06/11/2018 

Demographic Form   Document Date:  06/22/2018 

DME Prior Authorization Standard Request Form Document Date:  06/22/2018 

ECT Prior Authorization Request Document Date:  06/22/2018   

Electronic Fund Transfer (EFT) Form  Document Date:  01/11/2019 

Electronic Remittance Advice (ERA) Enrollment/Change/Cancellation Document Date:  06/29/2018 

Employment Education Demographic Update Form Document Date:  06/22/2018 

EPSDT Standards and Tracking Form   Document Date:  06/11/2018 

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

Flex Care Supportive Housing Application Document Date:  06/22/2018 

Hysterectomy Consent Form  Document Date:  06/12/2018 

Interagency PNO Client Transfer Form Document Date:  06/22/2018 

Level II PASRR Psychiatric Evaluation  Document Date:  06/22/2018 

Member's PCP Change Request Form Document Date:  06/22/2018 

Mercy Care RBHA Member Handbook Order Form  Document Date:  01/15/2019  NEW

Move In and Eviction Prevention Service Ticket  Document Date:  06/22/2018   

Move In and Eviction Prevention Checklist   Document Date:  06/22/2018   

Move In Assistance Request Process Checklist Document Date:  06/22/2018  

Move In Assistance Service Ticket   Document Date:  06/22/2018 

Moving Request   Document Date:  06/22/2018 

Network Material Change Transition Grid Template   Document Date:  06/22/2018     

Notification of persons in need of special assistance Document Date: 06/11/2018 

Oral Nutritional Supplements - Members 21 Years of Age and Older   Document Date:  06/12/2018 

Outpatient Behavioral Health Single Case Agreement  

PNO/Agency/Single POC Update

Prior Authorization DME Request Form Document Date:  06/22/2018 

Prior Authorization: Standard Request Form Document Date:  03/06/2018 

Prior Authorization for Family Planning 

Prior Authorization for Inpatient Eating Disorder Document Date:  06/22/2018 

Prior Authorization for Therapy and Home Health Request Form Document Date:  06/22/2018 

Provider Assistance Program Form  Document Date:  06/22/2018 

Psychiatric Security Review Board/GEI Conditional Release Monthly Report Document Date:  06/12/2017 

Psychiatric Rehabilitation Report Document Date:  06/22/2018 

Psychiatric Visit Information Form Document Date:  06/22/2018 

Psychological-Neuropsychological Testing Prior Authorization   Document Date:  06/22/2018 

RBHA and RSA/VR Referral Coordination Form  Document Date:  06/12/2018   

Re-Certification of Need (RON) Document Date:  06/25/2018 

Recovia Referral Form Document Date:  06/25/2018 

Referral for Behavioral Health Residential Facility Services Document Date:  06/25/2018 

Request for Direct Support or Specialty Provider Services Document Date:  06/25/2018  

Resubmission Form Document Date:  06/20/2018 

Scattered Site Housing Application   Document Date:  06/25/2018   

Seclusion and Restraint Individual Reporting Form   Document Date:  06/08/2018 

Secure Web Portal Registration Form Document Date:  06/25/2018 

SFTP Connectivity Enrollment Document Date:  06/25/2018 

Skilled Nursing Facility Continued Authorization Request   Document Date:  06/25/2018 

SMI Assessment Packet Checklist Document Date:  06/26/2018 

Specialist Referral Form   Document Date:  06/26/2018 

Special Treatment Plan for Forced Administration of Medications   Document Date:  06/26/2018 

Supervisory Care Home Monthly Progress Report   Document Date:  06/26/18 

Synagis (palivizumab) Authorization Form 2018-2019 Season Document Date:  10/08/2018  NEW

Temporary Extension Hotel Request Form Document Date:  06/26/2018 

Temporary Hotel Assistance Request Document Date:  06/26/2018   

Temporary Hotel Assistance Request Process Checklist   Document Date:  06/26/2018 

Therapeutic Residential Service Request for Children and Adolescents   Document Date:  06/26/2018 

Therapy & Home Health Prior Authorization Request Form Document Date:  06/26/2018 

Timely Filing Waiver Request Form  Document Date:  01/18/2019 NEW

Transitional Living and Planning Application Document Date:  06/13/2018 

Twenty-One Day Service Tracking Bi-Monthly Report With Instructions Document Date:  06/26/2018 

VI-SPDAT

Vocational Profile   Document Date:  06/12/2018 

Vocational Activity Profile Form -RS Only (English) Document Date:  06/12/2018   

Vocational Activity Profile Form -RS Only (Spanish) Document Date:  06/12/2018   

Waiver of 3 Day SMI Eligibility Determination (English) Document Date:  06/26/2018 

Waiver of 3 Day SMI Eligibility Determination (Spanish)   Document Date:  06/26/2018