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
-
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
Care Management Referral Form Document Date: 01/28/2021 NEW
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 NEW
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
-
Mercy Care RBHA Provider Forms
-
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
Authorization to Release Protected Health Information (PHI) English | Spanish|Arabic Date: 07/16/2021 NEW
AzAHP Organization-Facility Application Date: 08/05/2021 NEW
AzAHP Practitioner Data Form Date: 08/16/2021 NEW
AzAHP Provider Roster Template Date: 09/04/2019
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
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 Standards and Tracking Form Date: 05/16/2019
External ACC Care Management Referral Form Date: 04/08/2020
Exclusive Prescriber Program Referral Form Date: 10/16/2018
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 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: 05/18/2021
Missed Appointment Log Date: 08/13/2018
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
Prior Authorization DME Request Form Date: 06/22/2018
Prior Authorization Form for Substance Use Residential Document Date: 07/20/2021 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: 11/13/2020
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 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: 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: 11/10/2021 NEW
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
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: 1-866-237-0760Please Note: Aetna EFT forms WILL NOT be accepted.