| 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 (08/25/09) |
| CLAIMS RELATED |
Adjustment Request |
Vermont Health Access Program Adjustment Request Form |
|
Fillable PDF
|
CMS 1500 Medicare Attachment Summary Form (04/06/10) |
|
Fillable PDF
|
UB 04 Medicare Attachment Summary Form (05/07/10) |
| 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 (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 (06/29/10) |
| EDI (Electronic Data Interchange) |
EDI Registration |
EDI Registration Form (07/24/08) |
| Trading Partner |
Trading Partner Agreement (01/06/10) |
| ENROLLMENT |
Provider Enrollment |
New!!!
Provider Enrollment & Recertification Form - now with the option to edit and save (05/20/10)
Directions for filling out Provider Enrollment Form
|
| Non-Participating Provider Signature Page |
Non-participating providers must complete and return the Provider Enrollment & Recertification Form. Please substitute signature page 3 of the Provider Enrollment & Recertification Form with this non-participating signature page |
| 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. |
| FRAUD, WASTE and ABUSE |
Medicaid Fraud, Waste & Abuse Referral Form |
Report any concern about Fraud, Waste or Abuse of Medicaid funds or services (04/06/10) |
| 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. |
| 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 (08/11/10) |
| TRANSPORTATION |
Transportation Form |
In-State, Out of Area Medicaid Transportation Physician Referral Form (01/13/08) |
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