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Form Link Description(Post Date)
BENEFICIARY Accident Questionnaire Form required when DVHA has paid for medical care for a Medicaid or VHAP beneficiary, related to an accident/injury/illness/condition (11/03/11)
Alternate Reporter Request Use to appoint an "alternate reporter" to receive copies of notices about benefits from the Economic Services Division (ESD) of the Department for Children and Families (DCF). (2/3/11)
CLAIMS RELATED Adjustment Request Vermont Health Access Program Adjustment Request Form
CMS 1500 Summary Attachment Form PDF CMS 1500 Medicare Attachment Summary Form (9/5/14)
Directions for filling out the CMS 1500 Medicare Summary Attachment Form.
UB 04 Summary Attachment Form PDF UB 04 Medicare Attachment Summary Form (5/4/12)
Directions for filling out the UB 04 Medicare Summary Attachment Form.
DME Equipment Agreement form Durable Medical Equipment Ownership, Operation, and Maintenance Agreement (11/25/09)
Julian Calendar Julian Date Calendar (05/27/03)
Medicaid Refunds Vermont Medicaid Refunds Form (05/27/2015)
Multiple Adjustment Request Vermont Health Access Program Multiple Adjustment Request Form (01/03/11)
Provider Inquiry Provider Inquiry Form (01/14/10)
Timely Filing Appeal Listing Timely Filing Appeal Claim List is to be completed when submitting an appeal request containing 10 or more claims, all with the same late submission reason(08/26/11)
TPL Change Request Form Third Party Liability Change Request Form (8/30/11)
EDI Resources Link to HIPAA Tools Click to Access: EDI Registration, 835 Enrollment Form, Trading Partner Agreement, Companion Guide and 5010 Tech Specs (11-15-13)
ENROLLMENT Provider Enrollment Agreement Provider Enrollment Agreement
Now with the option to save & edit.
Directions for filling out Provider Enrollment Form
Recertification Agreement This Agreement is used for recertification when you have previously submitted a Provider Enrollment Agreement with a form date in the footer of 01/29/2010 or later.
Change of Address Change of address form for use by existing providers
Electronic Funds Transfer Request Form Vermont Health Access Program
Electronic Funds Transfer Request Form; use to set-up, change or terminate electronic funds transfer. Now with the option to save and edit.
Group Affiliation Request Group affiliation form for use by existing providers
PCPlus PCPlus Enrollment Form
PCPlus Naturopathic PCPlus agreement for naturopathic physicians.
Termination Notice To be used by existing providers wishing to terminate their enrollment in VT Medicaid
Web Services Account E-mail Request Form To be completed by providers wishing to establish a Web Services Account (03/29/11)
340B DRUG PROGRAM ENROLLMENT Hospital Enrollment Amendment 340B Hospital Enrollment Amendment - Mail to: HP Enterprise Services, Attn: 340B Enrollment, PO Box 1645, Williston, VT 05495
Provider Enrollment Amendment 340B Provider Enrollment Amendment - Mail to: HP Enterprise Services, Attn: 340B Enrollment, PO Box 1645, Williston, VT 05495
Contact Information Sheet 340B Covered Entity Contact Information Sheet. Return via e-mail to VT340b@hp.com.
340-B Medicaid Carve In Manual Program & Enrollment Guidelines
FRAUD, WASTE, ABUSE & TEAM CARE Medicaid Fraud, Waste & Abuse Referral Form Report any concern about Fraud, Waste or Abuse of Medicaid funds or services
PRIOR AUTHORIZATION & NOTIFICATION FORMS Authorization & Notification Request Forms Link to the Department of Vermont Health Access (DVHA) provider forms web page. Please click to access prior authorization request forms not listed below.
Dental Guidelines & Prior Authorization Forms Dental Guidelines & Dental Prior Authorization Form.
In-State Concurrent Review Procedures & Notification Form In-State Admission Notification Form & Inpatient Concurrent Review Procedures effective for all DOS on or after 7-1-12.
Answers to frequently asked questions(7-9-12)
Sterilization Consent Form Vermont Health Access Program
Sterilization Consent Form (01/09/13)
TRANSPORTATION Transportation Form In-State, Out of Area Medicaid Transportation Physician Referral Form (09/21/10)
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