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Forms
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 click on the appropriate form name below to get started.
- Appointment of Representative Form
- Behavioral Health Authorization Form
- CMS 1500
- Consent for Sterilization Form
- Electronic Funds Transfer (EFT) Form
- Electronic Remit Request Form
- GYN Prior Authorization Form
- Initial Request Form Ancillary
- Initial Request Form Professional
- Medicare Waiver of Liability Form
- Mercy Care Advantage Prior Authorization Form
- Mercy Care Advantage Remit Format for Check Form
- Mercy Care Advantage Remit Format for EFT Form
- Pharmacy Coverage Determination Form
- Prior Authorization DME Request Form
- Prior Authorization Therapy and Home Health Request Form
- Provider Notice Of Change Form
- Resubmission Form
- Specialty Medicine Authorization Form
4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Arizona 85040
Member Services
Available 24 hours per day, 7 days a week
602-263-3000,
Toll-free 1-800-624-3879
(TTY/TDD)
Toll-free: 1-866-602-1982
If you or a family member has a medical emergency, dial 911.