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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 for each plan

Order a member handbook

ACC-RBHA member handbook order form (PDF)

Other forms

AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)

AzAHP Non-Delegated Roster

AzAHP Organization-Facility Application (PDF)

AzAHP Practitioner Data Form (PDF)

AzAHP Practitioner Practice Change Form (PDF)

Bariatric Surgery Monthly Summary Worksheet (PDF)

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)

EPSDT Supply Order Form (PDF)  

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)   

PCP Change Request Form (PDF)

Perinatal Referral Form (PDF)   

Prior Authorization: Aetna Family Planning Service Request Form (PDF)

Prior Authorization: ABA Services (PDF)

Prior Authorization: Adult BHRF and ABHTH (PDF)

Prior Authorization: Children and Adolescents BHIF, BHRF, HCTC (PDF)

Prior Authorization: Clinical Trials (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 Financial Guide (PDF) 

Provider Assistance Program (PDF)

Resubmission Form (PDF)

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

Skilled Stay Continued Authorization Request (PDF)

Specialist Referral Form (PDF)

Subacute Detox Admission (PDF)

Order a member handbook

Member handbook order form

Other forms

ACC Psych Rehab Report

ACC Psychiatric Rehabilitation Reporting Deliverable Attestation (PDF)

ACT Exit Criteria Screening Tool Form (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 Forms (PDF)

ADCS Inpatient Assessment Report (PDF)

ADCS Outpatient Assessment Report (PDF)

ADCS Statement from Medical Director (PDF)

Adult HCTC Application (PDF)

AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)

AzAHP Non-Delegated Roster

AzAHP Organization-Facility Application (PDF)

AzAHP Practitioner Data Form (PDF)

AzAHP Practitioner Practice Change Form (PDF)

Bed Hold or Therapeutic Leave Request for Level I RTC (PDF)

Bridge to Permanency Housing Application (PDF)

Business Continuity and Incident Management Plan Checklist (PDF)

Care Management Referral Form (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)

Commercial Oral Nutritional Supplements (EPSDT) Members (DOCX)

Community Living Application (PDF)

Complex Case Review Form (PDF)

Consent for Assessment for Level of Care- English (PDF)

Consent for Assessment for Level of Care- Spanish (PDF)

Consent for Electroconvulsive Therapy (ECT) (PDF)

Consent to Treatment- English (PDF)

Consent to Treatment- Arabic (PDF)

Consent to Sterilization (DOCX)

Demographic Form (PDF)

DME Prior Authorization Standard Request Form (PDF)

ECT Prior Authorization Request (PDF)

EPSDT Clinical Sample Template (DOCX)

EPSDT Supply Order Form (PDF)

Eviction, Move In and Utilities Request Form (PDF)

Exclusive Prescriber Program Referral Form (PDF)

Hotel Assistance Extension Request (PDF)

Hotel Assistance Request (PDF)

Hysterectomy Consent Form (PDF)

Interagency PNO Client Transfer Form (PDF)

Level II PASRR Psychiatric Evaluation (PDF)

Missed Appointment Log (PDF)

Notification of Adult BHRF, Adult BHTH Admission (PDF)

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

Moving Assistance Request (PDF)

Network Material Change Transition Grid Template (PDF)

PCP Change Request Form (PDF)

Perinatal Form (PDF)

Prior Authorization: ABA Services (PDF)

Prior Authorization: BHRF and ABHTH (PDF)

Prior Authorization: Children and Adolescents BHIF, BHRF, HCTC (PDF)

Prior Authorization: Clinical Trials (PDF)

Prior Authorization: DME Request Form (PDF)

Prior Authorization: Inpatient Eating Disorder (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 Form (PDF)

Provider Financial Guide (PDF)

Psychiatric Security Review Board/GEI Conditional Release Monthly Report (PDF)

Psychiatric Visit Information Form (PDF)

Psychological-Neuropsychological Testing Prior Authorization (PDF)

RBHA and RSA/VR Referral Coordination Form (PDF)

RBHA Psychiatric Rehabilitation Attestation (PDF)

RBHA Psychiatric Rehabilitation Report (PDF)

Re-Certification of Need (RON) (PDF)

Recovia Referral Form (PDF)

Request for Direct Support or Specialty Provider Services (PDF)

Resubmission Form (PDF)

Scattered Site Housing Application (PDF)

Seclusion and Restraint Individual Reporting Form (PDF)

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

Skilled Nursing Facility Continued Authorization Request (PDF)

SMI Assessment Packet Checklist (PDF)

Specialist Referral Form (PDF)

Special Treatment Plan for Forced Administration of Medications (PDF)

Subacute Detox Admission Form (PDF)

Supervisory Care Home Monthly Progress Report (PDF)

Traditional Healing Request Form (PDF)

Transitional Living and Planning Application (PDF)

Twenty-One Day Service Tracking Bi-Monthly Report With Instructions (PDF)

VI-SPDAT (PDF)

Vocational Activity Profile Form -RS Only (English) (PDF)

Vocational 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)

AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)

AzAHP Non-Delegated Roster

AzAHP Organization-Facility Application (PDF)

AzAHP Practitioner Data Form (PDF)

AzAHP Practitioner Practice Change Form (PDF)

Bariatric Surgery Monthly Summary Worksheet (PDF)

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) 

EPSDT Supply Order Form (PDF)  

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)   

PCP Change Request Form (PDF)

Perinatal Referral Form (PDF)   

Prior Authorization: ABA Services (PDF)

Prior Authorization: Adult BHRF and ABHTH (PDF)

Prior Authorization: Children and Adolescents BHIF, BHRF, HCTC (PDF)

Prior Authorization: Clinical Trials (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 Form (PDF)

Provider Financial Guide (PDF)

Referral for Behavioral Health Services (PDF)

Resubmission Form (PDF)

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

Skilled Stay Continued Authorization Request (PDF)

Specialist Referral Form (PDF)

Subacute Detox Admission (PDF)

AHCCCS Behavioral Health Clinical Chart Audit Tool (XLXS)

AzAHP Non-Delegated Roster

AzAHP Organization-Facility Application (PDF)

AzAHP Practitioner Data Form (PDF)

AzAHP Practitioner Practice Change Form (PDF)

Bariatric Surgery Monthly Summary Worksheet (PDF)

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)

EPSDT Supply Order Form (PDF)  

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)   

PCP Change Request Form (PDF)

Perinatal Referral Form (PDF)  

Prior Authorization: ABA Services (PDF)

Prior Authorization: Adult BHRF and ABHTH (PDF)

Prior Authorization: Children and Adolescents BHIF, BHRF, HCTC (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 Financial Guide (PDF) 

Provider Assistance Program (PDF)

Resubmission Form (PDF) 

Skilled Stay Continued Authorization Request (PDF)

Specialist Referral Form (PDF)

Subacute Detox Admission (PDF)

You have access to our provider directory JSON files which 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)

Questions?

Check your provider manual for answers. Or contact us.