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Forms and provider manual attachments
Order a member handbook
Member handbook order form (PDF)
All forms
ACC-RBHA IHH/BHH Employment Related Training Attestation (PDF)
ACT-RBHA RSA/VR Referral Coordination Form (PDF)
ACT Team Residential/Flex Care/CLP with Outside ACT Supports Supplemental Form (PDF)
ADCS Inpatient Assessment Report (PDF)
ADCS Outpatient Assessment Report (PDF)
ADCS Statement from Medical Director/Designee of Residential Treatment Center (PDF)
ADCS Statement from Medical Director/Designee for Inpatient Psych Acute Care Hospital (PDF)
AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)
AHCCCS PASRR Psychiatric Evaluation (PDF)
AzAHP Organization-Facility Application
AzAHP Practitioner Practice Change Form
Bed Hold Therapeutic Leave Request (PDF)
Behavioral Health Service Referral Form (PDF)
Child/Adolescent Level 1 Discharge Plan Form (PDF)
Commercial Oral Nutritional Supplements (EPSDT) Members (DOCX)
Diabetes Prevention and Education Program Referral Form (PDF)
Exclusive Prescriber Program Referral Form (PDF)
Notification of Adult BHRF, Adult BHTH Admission (PDF)
Notification of Child and Adolescent BHIF, BHRT, TFC Admission (PDF)
Prior Authorization: ABA Services (PDF)
Prior Authorization: Adult BHRF and ABHTH (PDF)
Prior Authorization: Aetna Family Planning Service Request Form (PDF)
Prior Authorization: Children and Adolescents BHIF, BHRF, TFC (PDF)
Prior Authorization: Clinical Trials (PDF)
Prior Authorization: DME Request Form (PDF)
Prior Authorization: Standard Request Form (PDF)
Prior Authorization: Substance Use Residential (PDF)
Prior Authorization: Therapy and Home Health Request Form (PDF)
RBHA and RSA/VR Referral Coordination Form Maricopa (PDF)
Re-Certification of Need (RON) (PDF)
Seclusion and Restraint Individual Reporting Form (DOC)
Skilled Stay Continued Authorization Request (PDF)
SMI Assessment Packet Checklist (PDF)
Special Treatment Plan for Forced Administration of Medications (PDF)
Staff Competency ACOM 447 DB 101 Annual Attestation
Subacute Detox Admission Form (PDF)
Supervisory Care Home Monthly Progress Report (PDF)
Transitional Living and Planning Application (PDF)
Twenty-One Day Service Tracking Bi-Monthly Report With Instructions (PDF)
Vocational and Activity Profile Form -RS Only (English) (PDF)
Vocational and Activity Profile Form -RS Only (Spanish) (PDF)
Waiver of 3 Day SMI Eligibility Determination (English) (PDF)
Waiver of 3 Day SMI Eligibility Determination (Spanish) (PDF)
Order a member handbook
Member handbook order form (PDF)
Forms found in the provider manual
AHCCCS Appeal or Serious Mental Illness Grievance Form (DOC)
AHCCCS Application for Voluntary Evaluation (DOC)
AHCCCS Notice of Legal Rights for Members with Serious Mental Illness (DOC)
Authorization Criteria Adult SMI Behavioral Health Residential Facility (PDF)
Authorization Criteria for Behavioral Health Residential Facility Children/Adolescent (PDF)
Business Continuity and Incident Management Plan Checklist (PDF)
Certificate of Need (CON) (PDF)
Child and Adolescent 45 Day Clinical Review for Continued Prior Residential Facility (PDF)
Child and Adolescent 60 Day Clinical Review for Continued Stay Prior Authorization of HCTC (PDF)
CMS Appointment of Representative
Complex Case Review Form (PDF)
Consent to Sterilization (DOCX)
Electronic Remit Request Form (PDF)
EPSDT Clinical Sample Template (DOCX)
EPSDT Supply Order Form for DCS CHP (PDF)
Mercy Care nondiscrimination notice (PDF)
Mercy Care Advantage nondiscrimination notice (PDF)
Mercy Care Advantage Pharmacy Coverage Determination Form (PDF)
Prior Authorization: ABA Services (PDF)
Prior Authorization: Adult BHRF and ABHTH (PDF)
Prior Authorization: Aetna Family Planning Service Request Form (PDF)
Prior Authorization: Children and Adolescents BHIF, BHRF, TFC (PDF)
Prior Authorization: Inpatient Eating Disorder (PDF)
Prior Authorization: Standard Request Form (PDF)
Provider Assistance Program Form (PDF)
Psychiatric Visit Information Form (PDF)
Request for Direct Support or Specialty Provider Services (PDF)
Secure File Transfer Protocol (SFTP) Connectivity Enrollment Form (PDF)
AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)
AzAHP Organization-Facility Application
AzAHP Practitioner Practice Change Form
Behavioral Health Service Referral Form (PDF)
Care Management Referral Form (PDF)
Commercial Oral Nutritional Supplements (EPSDT) Members (DOCX)
Complex Case Review Form (PDF)
Consent to Sterilization (DOCX)
ECT Prior Authorization Request Form (PDF)
EPSDT Clinical Sample Template (DOCX)
Exclusive Prescriber Program Referral Form (PDF)
Hysterectomy Consent Form (PDF)
Missed Appointment Log (PDF)
Notification of Subacute Detox Admission (PDF)
Notification of Adult BHRF, Adult BHTH Admission (PDF)
Notification of Child and Adolescent BHIF, BHRT, TFC Admission (PDF)
Prior Authorization: ABA Services (PDF)
Prior Authorization: Adult BHRF and ABHTH (PDF)
Prior Authorization: Children and Adolescents BHIF, BHRF, TFC (PDF)
Prior Authorization: DME Request Form (PDF)
Prior Authorization: Therapy and Home Health Request Form (PDF)
Prior Authorization: Standard Request Form (PDF)
Prior Authorization: Substance Use Residential (PDF)
Provider Assistance Program (PDF)
Skilled Stay Continued Authorization Request (PDF)
Machine-readable files
Machine-readable files can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.
Mercy Care ACC-RBHA and DD Directory (JSON)
Mercy Care ACC-RBHA with SMI Directory (JSON)
Mercy Care LTC Directory (JSON)
Mercy Care DCS-CHP Directory (JSON)
Mercy Care ACC-RBHA, DD, DCS CHP, LTC formulary (JSON)
Mercy Care ACC-RBHA with SMI Behavioral Health Drug formulary (JSON)
Machine-readable files can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.
Mercy Care ACC-RBHA, DD, DCS CHP, LTC formulary (JSON)
Mercy Care ACC-RBHA with SMI Behavioral Health Drug formulary (JSON)
Check your provider manual for answers. Or contact us.