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. Submit EFT and ERA forms via secure e-mail or fax. Don't mail EFT and ERA forms.

Provider Manual Forms and 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 

Annual RBHA IHH/BHH Employment Related Training Attestation  Document Date:  06/15/2022 

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 

Care Management Referral Form Document Date: 08/2022 

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 2021 Statewide AHCCCS and ADES-RSA   Document Date:  12/22/2021 

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  

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 

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 

ACC Psych Rehab Report Date:  06/15/2022  NEW

ACC Psychiatric Rehabilitation Reporting Deliverable Attestation Date:  06/15/2022  NEW

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 

AHCCCS Behavioral Health Clinical Chart Audit Tool Date:  03/07/2022 

Authorization to Release Protected Health Information (PHI) English Spanish|Arabic  Date:  07/16/2021  

AzAHP Organization-Facility Application Date:  08/05/2021 

AzAHP Practitioner Data Form Date:  08/16/2021  

AzAHP Provider Roster Template  Date:  09/04/2019  

Bed Hold or Therapeutic Leave Request for Level I RTC    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   

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 Treatment (English)  Date:  07/01/2018

Consent to Treatment (Arabic) Date:  06/10/2020  

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:  06/28/2021

Electronic Remittance Advice (ERA) Form Date:  06/16/2021 

EPSDT Clinical Sample Template  Date:  02/2022 

EPSDT Supply Order Form Date:  03/22/2022

Eviction, Move In and Utilities Request Form Date:  07/18/2022  NEW

External ACC Care Management Referral Form  Date:  04/08/2020  

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

Hotel Assistance Extension Request  Date:  07/18/2022  NEW

Hotel Assistance Request Date:  07/18/2022 NEW

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 Notification of Adult BHRF & Adult BHTH Admission  Document Date:  12/8/2020  

Mercy Care Notification of Child & Adolescent BHIF, BHRT & TFC Admission  Document Date:  12/08/2020   

Mercy Care Web Portal Registration Form Date:  06/11/2021 

Mercy Care Web Portal Registration Form (Non-Par) Date:  06/11/2021 

Mercy Care RBHA SFTP Connectivity Form Date:  06/30/2022  NEW

Missed Appointment Log Date:  08/13/2018

Moving Assistance Request Date:  07/18/2022  NEW

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 

PNO/Agency/Single POC Update

Prior Authorization DME Request Form Date:  03/17/2022  

Prior Authorization Form for Substance Use Residential Document Date:  07/20/2021   

Prior Authorization: Standard Request Form Date:  03/17/2022  

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:  07/29/2022   Updated

Prior Authorization Request for ABA Services   Date:  01/28/2020 

Prior Authorization Request for BHRF and ABHTH Document Date:  11/27/2020  

Prior Authorization Request Form Children and Adolescents BHIF, BHRF, HCTC Document Date:  06/20/2020  

Provider Assistance Program Form   Date:  06/22/2018 

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

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   

RBHA Psychiatric Rehabilitation Attestation Date:  06/14/2022  

RBHA Psychiatric Rehabilitation Report Date:  06/14/2022  

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:  01/12/2022 

Scattered Site Housing Application   Date:  06/25/2018   

Seclusion and Restraint Individual Reporting Form    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:  10/12/2020 

Subacute Detox Admission Form Date: 11/15/2022  

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

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. 

 

Provider network files

This link provides our ACC-RBHA provider directory JSON file which can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.