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:  06/12/20188 

AzAHP Organizational Data Form   Document Date:  06/12/2018 

AzAHP Practitioner Data Form   Document Date:  06/12/2018 

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 for Treatment Form   Document Date:  06/22/2018 

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 Funds Transfer (EFT) Enrollment/Change/Cancellation   Document Date:  06/22/2018 

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 

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 

Notice of Adverse Benefit Determination   Document Date:  06/22/2018     

Notification of persons in need of special assistance (PDF)  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 (PDF)  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 

Single Case Agreement Rendering Provider Form   Document Date:  06/25/2018 

Single Case Agreement Initial Request Form   Document Date:  06/25/2018 

Single Case Agreement Extension Request Form   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 

Temporary Hotel Assistance Process Checklist   Document Date:  06/26/18 

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 

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