2023 small group details
2022 small group details
2022 small group summary of benefits and coverage (SBC) Illinois
2021 small group details
2021 small group summary of benefits and coverage (SBC) Illinois
2021 small group summary of benefits and coverage (SBC) Wisconsin
Additional 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): 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.
MercyCare HMO network: Our HMO network includes Mercyhealth providers and contracted providers. Please see map for details: Map
- Contracted providers: MercyCare contracts with Fort Healthcare, Watertown Regional Medical Center and others to provide healthcare to our members