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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)

    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 60 Day Review (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 Delegated Group Roster

    AzAHP Non-Delegated Roster

    AzAHP Organization-Facility Application

    AzAHP Practitioner Data Form 

    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)

    External Care Management Referral Form (PDF)

    Hysterectomy Consent Form (DOC)

    Notification of Adult BHRF (PDF)

    Notification of Child and Adolescent BHIF, BHRT, TFC Admission (PDF)   

    PCP Change Request 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: 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 for Central GSA (PDF)

    Re-Certification of Need (RON) (PDF)

    Recovia Referral Form (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

    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 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)

    Questions?

    Check your provider manual for answers. Or contact us. 

    Check your provider manual for answers. Or contact us.