Employer/ Group Applications
- WI large & small employer group application
- IL large employer group application
- IL small employer group application- Fillable
Employee Enrollment Applications
- WI large & small group employee enrollment application- Fillable
- IL large group employee enrollment application- Fillable
- IL small group employee enrollment application- Fillable
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.
- 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
Customer Service
For questions about your health plan benefits or to speak to a customer service, please call MercyCare at (800) 895-2421, Monday through Friday, from 8:00 am to 5:00 pm
580 N. Washington St, Janesville, WI 53548