Forms

Important provider forms


*** Important notice *** The EFT and ERA enrollment forms have changed. Enroll by downloading the paper forms.

Need help?
For questions regarding the forms or to check on enrollment status, please contact Provider Relations at 602-263-3000, Express Service Code 631.

You can also send us a message via our website using the Contact Us form


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.

 

Annual Wellness Visit Provider Form Document Date:  1/4/2019  NEW 

Appointment of Representative Form  Document Date:  1/3/2019  NEW

AzAHP Facility Application  Document Date:  03/06/2019  NEW

AzAHP Organizational Data Form  Document Date:  03/06/2019  NEW

AzAHP Practitioner Data Form  Document Date:  03/06/2019  NEW

AzAHP Provider Roster Template  Document Date:  06/12/2018 

Bariatric Surgery Monthly Summary Worksheet  Document Date:  06/13/2018 

Behavioral Health Referral Form  Document Date:  06/13/2018 

ECT Prior Authorization Request Form  Document Date:  06/13/2018   

Electronic Fund Transfer (EFT) Form Document Date:  09/21/2018 

Electronic Remittance Advice (ERA) Form  Document Date:  06/29/2018   

Hospice Information for Part D Plans  Document Date:  06/12/2018   

Medical Case Management Referral Form  Document Date:  06/19/2018 

Medicare Waiver of Liability Form  Document Date:  06/19/2018 

Mercy Care Advantage Remit Format for Check Form  Document Date:  06/19/2018 

Mercy Care Advantage Remit Format for EFT Form  Document Date:  06/19/2018 

Mercy Care Web Portal Registration Form  Document Date:  06/19/2018 

Missed Appointment Log  Document Date:  08/13/2018 

PCP Change Request Form  Docment Date:  06/19/2018 

Prior Authorization: DME Request Form  Document Date:  06/19/2018   

Prior Authorization: Standard Request Form  Document Date:  06/19/2018   

Prior Authorization: Therapy and Home Health Request Form  Document Date:  06/19/2018 

Provider Assistance Program  Document Date:  06/19/2018 

Request for Psychological Testing   Document Date:  06/19/2018    

Resubmission Form  Document Date:  06/19/2018 

Skilled Stay Continued Authorization Request  Document Date:  06/19/2018