Employer/ Group Applications
- WI large & small employer group application
- IL large employer group application
- IL small employer group application
Employee Enrollment Applications
- WI large & small group employee enrollment application
- IL large & small group employee enrollment application
Additional Forms
- Change of status- Fillable
- Member benefit guide
- Coordination of benefits
- Auto withdrawal form- Fillable
- Employer handbook- Administrative guide
- Provider appeal form
- Grievance appeal form
- Claim form 1500
- Transition of Care Request If you are newly switching insurance to MercyCare and are undergoing a current treatment, or late in your pregnancy, complete this form and fax to MercyCare for review by our utilization staff and medical director.
- Personal Health Information (PHI) release form FILLABLE VERSION: Use when a member would like MercyCare to provide personal health information to a third party. Examples of this include available benefits or claims information.
- Wellness Incentive Program Form (Only available to Illinois Large Groups)
- Stay Healthy Form FILLABLE VERSION Use to request reimbursement for health and wellness activities.
- Not available for Individual or Small Group Qualified Health Plans (QHP’s)
- Privacy notice
- Covered Preventive Services