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Form Link Description(Post Date)
BENEFICIARY Accident Questionaire 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
Fillable PDF CMS 1500 Medicare Attachment Summary Form (10/31/11)
Directions for filling out the CMS 1500 Medicare Summary Attachement Form.
Fillable PDF UB 04 Medicare Attachment Summary Form (10/31/11)
Directions for filling out the UB 04 Medicare Summary Attachement 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 (04/05/10)
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 (Electronic Data Interchange) EDI Registration EDI Registration Form (07/24/08)
Trading Partner Trading Partner Agreement (08/23/11)
ENROLLMENT Provider Enrollment
(11/09/2011)
***Use in place of form version 1-29-10***
Provider Enrollment & Recertification Form
now with the option to save & edit.
Directions for filling out Provider Enrollment Form
Electronic Funds Vermont Health Access Program
Authorization for Electronic Funds Transfer
Electronic Funds - Change Vermont Health Access Program
Change Information for Existing Electronic Funds Transfer
Change of Address Change of address form for use by existing providers.
Group Affiliation Request Group affiliation form for use by existing providers.
PCPlus PCPlus Enrollment Form
PCPlus Naturopathic PCPlus agreement for naturopathic physicians.
Termination Notice For use by existing providers.
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 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.
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 Abortion Form Abortion Certification Form (08/06/08)
Admission Notification Admission Notification for Out-of-State Hospital Psychiatric Inpatient Services (07/30/09)
Dental Prior Authorization Forms Dental forms for obtaining prior authorization.
Eyeglass Prior Authorization Form Medical Necessity Form (MNF) for eyeglasses (04/16/10)
Hysterectomy Consent Vermont Health Access Program
Hysterectomy Consent Form (08/06/08)
Medical Necessity Medical Necessity Form (MNF) for orthotics, prosthetics, medial supplies and equipment for in-home use (01/24/06)
Out of State Admissions Guidelines of Coverage for Out-of-State Admissions
Out of State Pre-Admission Out of State Pre-Admission Request form
Prior Authorization for Chiropractic Services form The DVHA Clinical Unit Prior Authorization for Chiropractic Services form. For temporary use until revised version becomes available.
Pre-Procedure Request Form Vermont Medicaid Pre-Procedure Request form. Pages 1 & 2 are mandatory and pages 3 & 4 are to be used when applicable.
Sterilization Consent Vermont Health Access Program
Sterilization Consent Form (02/03/11)
Therapy Extension Therapy Extension Form required for Physical, occupational and speech therapy services (01/26/09)
Urine Drug Test Form Urine Drug Test Prior Authorization Form (09/21/10)
TRANSPORTATION Transportation Form In-State, Out of Area Medicaid Transportation Physician Referral Form (09/21/10)
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