Get Az Mercy Care Outpatient Behavioral Health Non-par Provider Initial Single Case Agreement Request 2016-2025

Filling out the AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request form is an essential step for providers seeking authorization for services. This guide offers clear instructions to assist in completing the form accurately and efficiently.

Follow the steps to successfully complete the application form.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Enter today’s date in the designated field, ensuring it is formatted correctly.
3. Fill in the member information, including last name, first name, middle initial, date of birth, AHCCCS ID, and whether the member is a Medicare member.
4. Complete the clinical team information section with the provider organization name, address, TIN, NPI, and contact details.
5. In the rendering provider/facility information section, provide the rendering provider's name, doing business as (DBA) name, service address, and billing address, including city, state, and zip code.
6. Indicate whether the AHCCCS registration has been verified and include justification if the answer is 'No'.
7. Submit information about the service start and end dates, along with the current psychiatric diagnosis and relevant codes.
8. Provide details of any in-network providers contacted, including their names and the reasons for the request.
9. Complete the clinical justification for referral and discharge plan following the service completion, ensuring that all information is thorough and accurate.
10. Review the completed form for accuracy, then save changes. You may also choose to download, print, or share the form as needed.

Be sure to complete and submit your forms online to ensure timely processing of your request.