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.
- Discontinuation Form
- Change of status FILLABLE VERSION 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 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)
- 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.
- Claim form 1500
- Grievance appeal form
- Privacy notice
- Covered Preventive Services
- Member Benefit Guide (With Rx)
- Coordination of benefits
- Grievance appeal form
- Claim form 1500
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.
