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All Provider Forms

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 this 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

Last updated: 07/09/2020
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 six months during CDPAS recertification.
Download PDF: Form
Last updated: 03/18/2021

Demographic Update Form

Participating PCPs and Specialists: Here’s a quick and easy way to let us know about changes to your information!

EFT Request Form

To set up EFT payments, fill out this EFT Request Form by clicking on the link above.
Please note: in order to begin receiving EFT payments and remittances, you will also need to enroll with Availity to receive ERA files. See Electronic Payment for Providers for details.

Provider Claim Dispute Form

Use this form to submit your claims disputes online. A representative will get back to you shortly.

Delegated Roster Submissions

Delegated entities are required to submit monthly/quarterly provider rosters.

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: 02/05/2021

Request for Medicare Prescription Drug Coverage Redetermination

Download PDF: Redetermination Form
Last updated: 11/15/2020

New York State Medicaid Prior Authorization Request Form for Prescriptions

Last updated: 08/18/2022

Medicare Prior Authorization Requirements

Last updated: 08/12/2022

Pre-Authorization Request Form for VNS Health Managed Long Term Care Plans

Last updated: 09/14/2020

Opioids

Last updated: 11/25/2020

Diclofenac (Topical)

Last updated: 07/09/2020

High-Risk Medications

Last updated: 07/09/2020

High-Risk Non-Benzodiazepine Medications

Last updated: 07/09/2020

Skeletal Muscle Relaxants

Last updated: 07/09/2020

Lidocaine Patch and Ointment

RHIO Consent Forms

Authorization for Access to Patient/Member Information Through Health Information Exchanges

Download PDF: English Spanish
Last updated: 09/26/2022

Health Information Exchange Fact Sheet

Download PDF: English Spanish
Last updated: 11/08/2021