AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request Form 2015 free printable template

Instructions to Complete Outpatient Behavioral Health Sonar Provider Single Case Agreement Request Form (These instructions are intended to eliminate delays in processing) This form must be completed

How to fill out example of a single

How to fill out AZ Mercy Care Outpatient Behavioral Health Non-Par

1. Obtain the AZ Mercy Care Outpatient Behavioral Health Non-Par form from the official website or local office.
2. Read through the instructions carefully to understand the required information.
3. Fill in the patient's personal details, including full name, date of birth, and contact information.
4. Provide the insurance details for the patient, including policy number and group number.
5. Detail any relevant medical history or behavioral health issues in the appropriate section.
6. Include information about the referring provider, if applicable.
7. Sign and date the form where indicated.
8. Submit the completed form via mail, fax, or online as directed.

Who needs AZ Mercy Care Outpatient Behavioral Health Non-Par?

1. Individuals seeking outpatient behavioral health services who are not enrolled in a Mercy Care plan.
2. Patients who require access to behavioral health resources but do not have an active contract with Mercy Care.
3. Providers seeking coverage authorization for non-participating providers to deliver outpatient behavioral health services.

For pdfFiller’s FAQs

How can I send example of a single for eSignature?

When you're ready to share your example of a single, you can send it to other people and get the eSigned document back just as quickly. Share your PDF by email, fax, text message, or USPS mail. You can also notarize your PDF on the web. You don't have to leave your account to do this.

Where do I find example of a single?

It's simple using pdfFiller, an online document management tool. Use our huge online form collection (over 25M fillable forms) to quickly discover the example of a single. Open it immediately and start altering it with sophisticated capabilities.

How do I edit example of a single on an Android device?

You can. With the pdfFiller Android app, you can edit, sign, and distribute example of a single from anywhere with an internet connection. Take use of the app's mobile capabilities.

What is AZ Mercy Care Outpatient Behavioral Health Non-Par?

AZ Mercy Care Outpatient Behavioral Health Non-Par refers to the outpatient behavioral health services provided by Arizona Mercy Care that are not part of the in-network provider system. This means that the services rendered are outside of the contracted network.

Who is required to file AZ Mercy Care Outpatient Behavioral Health Non-Par?

Providers who deliver outpatient behavioral health services to members of AZ Mercy Care that do not participate in the network are required to file AZ Mercy Care Outpatient Behavioral Health Non-Par.

How to fill out AZ Mercy Care Outpatient Behavioral Health Non-Par?

To fill out the AZ Mercy Care Outpatient Behavioral Health Non-Par form, providers need to complete the required sections with relevant patient information, services rendered, and diagnosis codes, ensuring that all details are accurate and comply with the submission guidelines provided by AZ Mercy Care.

What is the purpose of AZ Mercy Care Outpatient Behavioral Health Non-Par?

The purpose of AZ Mercy Care Outpatient Behavioral Health Non-Par is to document and seek reimbursement for behavioral health services provided to members by non-participating providers, ensuring that members have access to necessary care even outside the network.

What information must be reported on AZ Mercy Care Outpatient Behavioral Health Non-Par?

Information that must be reported includes patient identification details, date of service, type of services rendered, diagnosis codes, provider's details, and any relevant medical necessity documentation to justify the services provided.