Forms

Important provider forms


*** Important notice *** ERA and EFT 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.

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

AzAHP Facility Application  Document Date:  06/12/2018  NEW

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

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

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

Bariatric Surgery Monthly Summary Worksheet  Document Date:  06/20/2018  NEW

Commercial Oral Nutritional Supplements (EPSDT Members)  Document Date:  06/20/2018  NEW

Consent to Sterilization  Document Date:  06/12/2018  NEW

Developmental Screening Tool Attestation Form  Document Date:  06/20/2018  NEW

ECT Prior Authorization Request Form  Document Date:  06/20/2018  NEW

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

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

EPSDT Standards and Tracking Forms  Document Date:  06/12/2018  NEW

EPSDT Supply Order Form  Document Date:  06/20/2018  NEW

Hysterectomy Consent Form  Document Date:  06/12/2018  NEW   

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

Mercy Care Complete Care Remit Format for Check Form  Document Date:  06/20/2018  NEW

Mercy Care Complete Care Remit Format for EFT Form  Document Date:  06/20/2018  NEW

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

Missed Appointment Log Document Date:  08/13/2018  NEW

Oral Nutritional Supplements (Members 21 Years of Age and Older)  Document Date:  06/12/2018  NEW

PCP Change Request Form  Document Date:  06/19/2018  NEW

Perinatal Referral Form  Document Date:  07/25/2018  NEW

Prior Authorization: Aetna Family Planning Service Request Form

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

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

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

Prior Authorization: Transcranial Magnetic Stimulation  Document Date:  07/27/2018  NEW

Provider Assistance Program  Document Date:  06/19/2018  NEW

Referral for Behavioral Health Services 

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

Resubmission Form  Document Date:  06/19/2018  NEW

SA FPS Remit Format for Check Form

SA FPS Remit Format for EFT Form

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

Synagis (palivizumab) authorization form 2017-2018 season  Document Date:  06/20/2018  NEW