- Wisconsin large employer group application
- Wisconsin small employer group application
- Illinois large employer group application
- Illinois small employer group application
Employee enrollment applications
- Wisconsin large & small group employee enrollment application
- Illinois large & small group employee enrollment application
- Out of area dependent coverage form. Certain large group members only. Check "My Plan Documents" to see if you are eligible for this coverage.
- 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). 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.
- Wellness Incentive Program form. (Only available to Illinois large groups.)
- Stay Healthy form (fillable). Use to request reimbursement for health and wellness activities. Not available for individual or small group qualified health plans (QHPs).
- Privacy notice
- Covered preventive services
- Dilated retinal eye exam communication form