- 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): 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): 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): Use to request reimbursement for health and wellness activities.
- Not available for individual or small group qualified health plans.
- 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
- Out of Area Dependent Form
- OTC-COVID 19 At Home Test Claim Form
- Eye Exam Form
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.