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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 (11/02/2015)
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 (editable PDF) with instructions for filling out the CMS 1500 Medicare Summary Attachment Form. (11/02/15)
UB 04 Summary Attachment Form PDF UB 04 Medicare Attachment Summary Form (editable PDF) with instructions for filling out the UB 04 Medicare Summary Attachment Form. (11/02/15)
DME Equipment Agreement form Durable Medical Equipment Ownership, Operation, and Maintenance Agreement (11/25/09)
Julian Calendar Julian Date Calendar (11/02/15)
Medicaid Refunds Vermont Medicaid Refunds Form (11/02/15)
Multiple Adjustment Request Vermont Health Access Program Multiple Adjustment Request Form (11/02/15)
Provider Inquiry Provider Inquiry Form (11/02/15)
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(11/02/15)
TPL Change Request Form Third Party Liability Change Request Form (11/02/15)
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 Link to Provider Enrollment Click to Access: All Provider Enrollment, Revalidation, and Data Maintenance forms as well as notifications and instruction on the Enrollment process.
340B DRUG PROGRAM ENROLLMENT Hospital Enrollment Amendment 340B Hospital Enrollment Amendment - Mail to: Hewlett Packard Enterprise, Attn: 340B Enrollment, PO Box 1645, Williston, VT 05495
Provider Enrollment Amendment 340B Provider Enrollment Amendment - Mail to: Hewlett Packard Enterprise, Attn: 340B Enrollment, PO Box 1645, Williston, VT 05495
Contact Information Sheet 340B Covered Entity Contact Information Sheet. Return via e-mail to VT340b@hpe.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.
Pharmacy Guidelines & Prior Authorization Forms Pharmacy Guidelines & Pharmacy 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 Opens link to the Sterilization Consent form
TRANSPORTATION Transportation Form In-State, Out of Area Medicaid Transportation Physician Referral Form (09/21/10)
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