Below you will find many of the forms and documents you may need. If you don’t see a form or document you need on this page, please click here to contact us.
To locate your specific plan documents click here
Forms and Documents
- MYCHART UPDATE- Instructions
- 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.
- Change of status: Use to change member information such as your name, coverage election(s) or termination of coverage benefits. General Motors employees must contact the National Benefits Center at (800) 489-4646. Forms must be signed by your employer prior to submission to MercyCare.
- Personal Health Informaion (PHI) release form: 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 Use to request reimbursement for health and wellness activities.
- Not available for Individual or Small Group Qualified Health Plans (QHP’s)
- Stay healthy benefit reimbursement form: (MERCY HEALTH PARTNERS)
- Auto withdrawal form: Use to authorize MercyCare to take premiums due directly from a checking or savings account. This is limited to members who pay premiums directly to MercyCare.
- Grievance appeal form
- Privacy notice
- Covered Preventive Services
- MCHP Member Benefit Directory (With Rx)
Prescription Drug Claim Forms
*Not all members receive drug plan benefits through MercyCare. If you would like to verify your prescription drug benefits, please contact your employer or MercyCare’s customer service department at (800) 895-2421.
