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)