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 

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

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

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

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

Behavioral Health Counseling Auth Renewal Form

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

Consent to Sterilization - Attachment A  Document Date:  06/12/2018 

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

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

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

EPSDT Standard and Tracking Forms  Document Date:  06/12/2018   

Hysterectomy Consent Form  Document Date:  06/12/2018 

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

Mercy Care Long Term Care Remit Form for Check Document Date:  06/20/2018 

Mercy Care Long Term Care Remit Form for EFT  Document Date:  06/20/2018 

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

Missed Appointment Log  Document Date:  08/13/2018 

Oral Nutritional Supplements (Members 21 Years or Older)  Document Date:  06/12/2018 

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

Perinatal Referral Form  Document Date:  07/25/2018 

Prior Authorization: DME Request Form  Document Date:  06/19/2017   

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

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

Provider Authorization: Transcranial Magnetic Stimulation  Document Date:  07/27/2018 

Provider Assistance Program   Document Date:  06/19/2018  

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

Resubmission Form  Document Date:  06/19/2018 

Seclusion and Restraint Individual Reporting Form  Document Date:  06/12/2018 

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