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
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Mercy Care RBHA Provider Manual Attachments
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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
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Mercy Care RBHA Provider Forms
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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
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
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