Add-Change-Term Request Forms

You can now submit your network and directory change requests online!

New processes can be challenging, so we created a user guide for each form and a FAQ. If needed, you can contact Provider Relations for assistance.

Add Form

Add a new office location
Add an existing provider to an existing office location
View tutorial

Change Form

Changes to existing provider information such as address, Medicaid number
Add or remove panels / plans
Tax ID change or change of ownership
View tutorial

Termination Form

Terminate office location
Remove provider from office location
View tutorial

Not yet in our networks?

We’d love to have you!

Provider Forms FAQs

Add Form FAQs

What is the Provider Add Form?

This form is to be used when adding a new office location with an Eye Care Professional who is already credentialed. It is also used to add an existing ECP to an existing office location and when adding a new office location without exam service by an ECP; a frame dispense location only.

Why do you need so much information?

The questions on the form facilitate the set up of the office, we need to know where the office is located, how the company and members can contact you, what hours you are open, do you accept Medicaid, can a member access you through public transportation? These items are all reflected in the member directory, we need to provide them with as much information as possible to allow an informed decision.

Why do you need a copy of my W-9 if I already have set up billing?

The W-9 is used to confirm we are adding the information or ECP to the correct account. If they do not match, we will contact you to ensure we are using the correct account.

How long does it take to get my office set up?

Most changes occur within 15 business days, but no longer than 30 days.

Why do I have to complete and ADA form and DOO Form?

Although these forms are required by CMS, Versant Health collects the forms for all our providers, to minimize duplicate work; we will utilize the information from these forms to complete your request.

I am still not sure if I am using the right form?

Not to worry, check the other FAQs, see the tutorials, and if still not sure, do your best, if additional information is needed a Network Operations Data Specialist will reach out to you at the e-mail provided.

Change Form FAQs

What is the Provider Change Form?

This form is to be used when making a change or update to your existing office information. This can be to your account information or directory.

What can I change?

Almost anything can be changed! Phone number, fax number, e-mail, website address, contact information, panels and services, hours of operation, tax id number, which Eye Care Professional is providing exam services.

How long until the change takes place?

Most changes occur within 15 business days. If a new office number is needed, an additional 2 days is required to complete the back end portion of the setup, a Network Operations Data Specialist will reach out to the e-mail provided to notify you when the 2 day changeover will occur and provide your new office number.

Can I speak with someone about changing my rates or fees?

Yes! But not in Network Operations, please contact our customer service number to obtain a copy of your current fee schedule, your contract, and to request to have a representative contact you.

How long before I see the change in the portal?

Most changes occur within 15 business days, but no longer than 30 days.

I am still not sure if I am using the right form?

Termination Form FAQs

What is the Provider Termination Form?

This form is to be used when terminating an office location, or an Eye Care Professional from the Davis Vision or Superior Vision network, or both networks.

What happens when I decide to terminate my participation?

Although we are sad to see you go, we understand this is a partnership. Once we receive the notification, we will set a termination date based on your provider agreement typically 60 or 90 days. A Network Operations Data Specialist will reach out to the e-mail provided to confirm the actual termination date. They will also confirm the address to send return materials if you have a frame collection to return. Once the date arrives the office number will be terminated in the system. You will no longer be reflected in the provider directory or have access to the online portal. (access will continue if you have other active office locations).

Why do I need to wait 90 days (or 60 days per agreement)?

This is allow both partners time to notify members and adjust to the change.

What happens if I still need to submit billing, or a lab redo?

Not to worry, you can still submit via the fax number on the paper forms.

I’ve changed my mind, I want to come back?

Wonderful! We are happy to have you back, depending on the length of time, we may need to redo the credentialing process, please visit the page to join the network and submit your information. A recruiter will contact you to obtain any necessary information.