Forms for Providers and Patients
Here you can find forms to join our network, update your demographic information, get prior authorizations for a patient’s medications, and more. You can find credentialing forms by clicking on this link.
Required for All Current Providers
Provider Disclosure Certification
You are required to fill out and return the provider disclosure certification form to VNS Health Health Plans. Please return it by December 31, 2021.
You can scan the completed document and email it as an attachment to: [email protected].
Or you can print it out and mail it to:
VNS Health
Health Plans – Provider Operations
220 East 42nd Street
New York, NY 10017
Download PDF:
NYSDOH Provider Disclosure Certification
Last updated: July 9, 2020
Forms for New Providers
Join Our Provider Network
Thank you for your interest in joining our provider network. To get started, please submit your request for participation.
Forms for Current Providers
CDPAS Recertification – Physician Order Form
VNS Health Total and VNS Health MLTC members can have their home care service provided by a consumer directed personal care assistant through Consumer Directed Personal Assistance Services (CDPAS). The physician order form is required during the initial assessment and every 6 months during CDPAS recertification.
Download PDF:
Form
Last updated: March 18, 2021
Demographic Update Form
Participating primary care providers and specialists, here’s a quick and easy way to let us know about changes to your information!
EFT Request Form
To set up electronic funds transfer (EFT) payments, fill out this EFT Request Form by clicking on the link above.
Please note that to begin receiving EFT payments and remittances, you will also need to enroll with Availity to receive electronic remittance advice files. See Electronic Payment for Providers for details.
Please note that to begin receiving EFT payments and remittances, you will also need to enroll with Availity to receive electronic remittance advice files. See Electronic Payment for Providers for details.
Provider Claims Dispute Form
Use this form to submit your claims disputes online. A representative will get back to you shortly.
Delegated Roster Submission
Delegated entities are required to submit monthly/quarterly provider rosters.
- The Delegated Entities Provider Roster Template consists of:
- Provider termination/add/update
- Location termination/add
- Demographic updates/removals
Visit our Credentialing page for more information.
Prior Authorization Request Forms
Request for Medicare Prescription Drug Coverage Determination –
PDF Form
Download PDF:
Determination Form
Last updated: March 31, 2023
Request for Medicare Prescription Drug Coverage Redetermination
Download PDF:
Redetermination Form
Last updated: November 15, 2020
New York State Medicaid Prior Authorization Request Form for Prescriptions
Download PDF:
NYS Medicaid Prior Authorization Request Form
Last updated: March 31, 2023
Medicare Prior Authorization Requirements
Download PDF:
Medicare Prior Authorization Requirements
Last updated: August 12, 2022
Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans
Download PDF:
Pre-Authorization Request Form
Last updated: September 14, 2020