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.

Forms and Documents

• Transition of Care-New Enrollees: 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 Preventative Services
• MCHP Member Benefit Directory (With Rx)

Prescription Drug Claim Forms

• Foreign claim – direct member reimbursement
• Compound claim
• Direct member reimbursement

*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.

Large Group and Non-Qualified Health Plans (QHPs)

• Large and Small Group HMO Certificate of Coverage
• Large and Small Group HMO HSA Certificate of Coverage
  • Large Group HMO & HMO HSA Certificate of Coverage Amendments
• Large and Small Group EPO Certificate of Coverage
• Large and Small Group PLUS Certificate of Coverage
• Large Group Plus Certificate of Coverage Amendments
• Large and Small Group POS Certificate of Coverage
  • Large Group POS Certificate of Coverage Amendments
• Large Group PPO Certificate of Coverage
• Large Group PPO HSA Certificate of Coverage

Individual Health Plans

• Individual Certificate of Coverage- On and Off Exchange

WI-Small Group Qualified Health Plans (QHPs)

• WI Certificate of Coverage – EPO
• WI Certificate of Coverage – HMO
• WI Certificate of Coverage – PPO

IL-Small Group Qualified Health Plans (QHPs)

• IL Certificate of Coverage- HMO off-exchange
• IL Prescription Drug Rider- HMO off exchange