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Forms

Form	Link	Description(Post Date)
BENEFICIARY	Accident Questionaire	Form required when OVHA has paid for medical care for a Medicaid or VHAP beneficiary, related to an accident/injury/illness/condition (08/25/09)
CLAIMS RELATED	Adjustment Request	Vermont Health Access Program Adjustment Request Form
	Fillable document Non-Fillable PDF	CMS 1500 Medicare Attachment Summary Form (11/12/09)
	Fillable document Non-Fillable PDF	UB 04 Medicare Attachment Summary Form (11/12/09)
	Device Order	Omni 3740 Terminal Device Order Form (09/24/04)
	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 (04/15/08)
	Multiple Adjustment Request	Vermont Health Access Program Multiple Adjustment Request Form (05/22/07)
	Provider Inquiry	Provider Inquiry Form (01/14/10)
	Sterilization Consent	Vermont Health Access Program Sterilization Consent Form (08/30/04)
	TPL Change Request Form	Third Party Liability Change Request Form (02/08/10)
EDI (Electronic Data Interchange)	EDI Registration	EDI Registration Form (07/24/08)
EDI (Electronic Data Interchange)	Trading Partner	Trading Partner Agreement (01/06/10)
ENROLLMENT	Provider Enrollment	New!!! Provider Enrollment Form - now with the option to edit and save (02/01/10)
	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.
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.
	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 OVHA 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.
	Therapy Extension	Therapy Extension Form required for Physical, occupational and speech therapy services (01/26/09)
TRANSPORTATION	Transportation Form	In-State, Out of Area Medicaid Transportation Physician Referral Form (01/13/08)



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