نماذج مقدمي الخدمات

*** إخطار مهم *** تم تغيير نماذج تسجيل ERA وEFT. التسجيل من خلال تنزيل النماذج الورقية.

هل تحتاج إلى مساعدة؟ لطرح أسئلة بخصوص النماذج أو للتحقق من حالة التسجيل، يرجى الاتصال بعلاقات مقدمي الخدمات على الرقم 602-263-3000.

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 cick on the appropriate form name below to get started

AzAHP Facility Application Document Date:  02/03/2020  NEW

AzAHP Organizational Data Form Document Date:  02/03/2020  NEW

AzAHP Practitioner Data Form Document Date:  02/03/2020  NEW

AzAHP Provider Roster Template Document Date:  09/04/2019 

ورقة عمل شهرية لملخص جراحة علاج البدانة   Document Date:  06/20/2018  

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

Complex Case Review Form  Document Date:  06/20/2018

Consent to Sterilization  Document Date:  06/12/2018   

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

Electronic Funds Transfer (EFT) Form  Document Date:  01/11/2019  

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

EPSDT Standards and Tracking Forms Document Date:  05/16/2019   

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

Exclusive Prescriber Program Referral Form Document Date:  10/16/2018 

Hysterectomy Consent Form   Document Date:  06/12/2018     

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

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

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

Mercy Care Web Portal Registration Form Document Date:  07/31/2019 

Mercy Care Web Portal Registration Form (Non-Par) Document Date:  11/11/2019 

Missed Appointment Log  Document Date: 08/07/2018 

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

PCP Change Request Form Document Date:  08/29/19  

Perinatal Referral Form Document Date:  10/23/2019  

التصريح المسبق: نموذج طلب خدمات تنظيم الأسرة في Aetna

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

Prior Authorization: GMH/SU Residential Substance Use  Document Date:  02/11/2020  NEW 

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

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

Prior Authorization Request for ABA Services Document Date:  01/28/2020  NEW

Prior Authorization Request Form for Adult BHRF Document Date:  06/19/2020 UPDATED

Prior Authorization Request Form for Children and Adolescents BHIF, BHRF, HCTC Document Date:  06/19/2020  UPDATED

Provider Assistance Program   Document Date:  06/19/2018  

Referral for Behavioral Health Services

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

Resubmission Form   Document Date:  06/19/2018  

نموذج تحويل SA FPS إلى نموذج شيك

نموذج تحويل SA FPS إلى نموذج تحويل الرصيد الإلكتروني

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

Specialist Referral Form   Date:  06/26/2018

 

تحويل الأموال الإلكتروني

التسجيل لتلقي الأموال إلكترونيًا

Mercy Care offers electronic funds payment directly to your bank account for your convenience. If you are interested in this payment option, download the Electronic Funds Transfer (EFT) Form. Complete the EFT Form in its entirety (including two authorized signatures), and fax it along with a voided check or a formal letter from your banking institution for verification of your bank account number to:

Mercy Care

Attn: Mercy Care Finance EFT Enrollment

Fax: 1-866-237-0760

Please Note:  Aetna EFT forms WILL NOT be accepted.