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Provider forms

Need to file a claim, tell us about your change of address or request prior authorization for a treatment? Just complete the right form. Then, we can respond to your needs quickly and efficiently. Be sure you check back here for updates. We update the forms regularly to improve your experience.

 

Forms and provider manual attachments

Order a member handbook

Member handbook order form (PDF)

Forms found in the provider manual

Adult HCTC Application (PDF)

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 (PDF)  

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)

Missed Appointment Log (PDF)

Perinatal Referral 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)

Resubmission Form (PDF)

Request for Direct Support or Specialty Provider Services (PDF)

Secure File Transfer Protocol (SFTP) Connectivity Enrollment Form (PDF)

Specialist Referral Form (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, DD, DCS CHP, LTC formulary (JSON)

Mercy Care ACC-RBHA with SMI Behavioral Health Drug formulary (JSON)

Questions?

Check your provider manual for answers. Or contact us.