نماذج مقدمي الخدمات

*** إخطار مهم *** تم تغيير نماذج تسجيل EFT وERA. التسجيل من خلال تنزيل النماذج الورقية.

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

سواء كنت تريد تقديم مطالبة أو إبلاغنا بتغيير في العنوان أو طلب تصريح مسبق لعلاج معين، فإن تعبئة النماذج الضرورية ستساعدنا في الاستجابة لاحتياجاتك بسرعة وكفاءة. ما عليك إلا النقر فوق اسم النموذج المناسب أدناه للبدء.

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

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

AzAHP Facility Credentialing and Recredentialing Application Document Date: 2/3/2020  NEW

AzAHP Organizational Data Form Document Date: 2/3/2020  NEW

AzAHP Practitioner Data Form Document Date: 2/3/2020  NEW

AzAHP Provider Roster template Document Date: 9/4/2019

Bariatric Surgery Monthly Summary Worksheet Document Date: 6/12/2018

Behavioral Health Referral Form Document Date: 6/13/2018

ECT Prior Authorization Request Form Document Date: 6/13/2018

Electronic Fund Transfer (EFT) Form Document Date: 9/21/2018

Electronic Remittance Advice (ERA) Form Document Date: 6/29/2018

Hospice Information for Part D Plans Document Date: 11/18/2019

Medical Case Management Referral Form Document Date: 6/19/2018

Medicare Waiver of Liability Form Document Date: 6/19/2018

Mercy Care Advantage Remit Format for Check Form Document Date: 6/19/2018

Mercy Care Advantage Remit Format for EFT Form Document Date: 6/19/2018

Mercy Care Web Portal Registration Form Document Date: 7/31/2019

Mercy Care Web Portal Registration Form (Non-Par) Document Date: 10/19/2019

Missed Appointment Log Document Date: 8/13/2018

PCP Change Request Form Document Date: 8/29/2019

Prior Authorization: DME Request Form Document Date: 6/19/2018

Prior Authorization: Standard Request Form Document Date: 6/19/2018

Prior Authorization: Therapy and Home Health Request Form Document Date: 6/19/2018

Provider Assistance Program Form Document Date: 6/19/2018

Request for Psychological Testing Form Document Date: 6/19/2018

Resubmission Form Document Date: 6/19/2018

Skilled Stay Continued Authorization Request Form Document Date: 6/19/2018