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 2019 Statewide AHCCCS and ADES-RSA   Document Date:  10/01/2018 

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 RBHA Remit Format for Check Document Date:  06/11/2018 

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

Mercy RBHA Financial Reporting Guide Document Date:  09/29/2014

Mercy RBHA Financial Report Guide Attachment Document Date:  09/29/2014

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  Date:  06/13/2018 

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

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

ADCS 60 Day Review Document Date:  11/04/2019

ADCS Forms Document Date:  11/04/2019

ADCS Inpatient Assessment Report Document Date:  11/04/2019 

ADCS Outpatient Assessment Report Document Date:  11/04/2019

ADCS Statement from Medical Director Document Date:  11/04/2019

Adult HCTC Application  Date:  06/13/2018 

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

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

AzAHP Facility Application Date:  01/01/2019 

AzAHP Organizational Data Form Date:  01/01/2019 

AzAHP Practitioner Data Form Date:  01/01/2019 

AzAHP Provider Roster Template  Date:  09/04/2019  NEW

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

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

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

Biohazard Cleaning Request  Date:  06/12/2018 

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

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

Certificate of Need (CON)   Document Date:  10/02/2019  NEW 

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

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

Community Living Application  Date:  06/20/2018 

Complex Case Review Form    Date:  06/20/2018 

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

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

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

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

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

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

Crisis Response Network Forms    Date:  06/11/2018 

Demographic Form   Date:  06/22/2018 

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

ECT Prior Authorization Request  Date:  06/22/2018   

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

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

EPSDT Standards and Tracking Form  Date:  05/16/2019 

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

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

Hysterectomy Consent Form   Date:  06/12/2018 

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

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

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

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

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

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

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

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

Moving Request   Date:  06/22/2018 

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

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

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

Perinatal Form Document Date:  10/23/2019  NEW

PNO/Agency/Single POC Update

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

Prior Authorization: GMH/SU Residential Substance Use Document Date:  06/06/2019  NEW

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

Prior Authorization for Family Planning 

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

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

Prior Authorization Request Form Adult BHRF Date:  04/26/2019

Prior Authorization Request Form Children and Adolescents BHIF, BHRF, HCTC Date:  04/26/2019

Provider Assistance Program Form   Date:  06/22/2018 

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

Psychiatric Rehabilitation Report Date:  06/22/2019 

Psychiatric Visit Information Form  Date:  06/22/2018 

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

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

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

Recovia Referral Form  Date:  06/25/2018 

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

Resubmission Form  Date:  06/20/2018 

Scattered Site Housing Application   Date:  06/25/2018   

Seclusion and Restraint Individual Reporting Form    Date:  06/25/2018   

Secure Web Portal Registration Form Date:  07/10/2019 

Secure Web Portal Registration Form (Non-Par) Date:  11/11/2019  NEW

SFTP Connectivity Enrollment  Date:  06/25/2018 

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

SMI Assessment Packet Checklist   Date:  06/26/2018 

Specialist Referral Form   Date:  06/26/2018 

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

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

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

Temporary Hotel Assistance Request  Date:  06/26/2018   

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

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

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

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

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

VI-SPDAT

Vocational Activity Profile Form -RS Only (English) Date:  06/07/2019

Vocational Activity Profile Form -RS Only (Spanish) Date:  06/07/2019   

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

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

 

Electronic Funds Transfer

Sign up to receive funds electronically

Mercy Care offers electronic funds payment directly to your bank account for your convenience. If you are interested in this payment option, download the Electronic Funds Transfer (EFT) Form. Complete the EFT Form in its entirety (including two authorized signatures), and fax it along with a voided check or a formal letter from your banking institution for verification of your bank account number to:

Mercy Care

Attn: Mercy Care Finance EFT Enrollment

Fax: 1-866-237-0760

Please Note:  Aetna EFT forms WILL NOT be accepted.