Add a Provider to Your Contracted Group

The forms below must be completed to add a Provider to your existing Mercy Care Plan Group Contract.

• Initial Request Form - Professional
• Attachment C
• Initial Request Form - Ancillary/Facility

In order to process this request, please return these documents via fax at (602) 263-3034, attention Cathy Garr, Network Development & Contracting. You can also submit this paperwork via mail at the address listed below.

Mercy Care Plan/Mercy Care Advantage
Attn: Cathy Garr, Network Development & Contracting
4350 E. Cotton Center Blvd.
Bldg D
Phoenix, Arizona 85040