Forms Library

Are you a Provider and looking for a specific Virginia Premier form or document? Find forms quickly in our Provider Forms Library by either searching by the type of file you need.

Claims and EDI Forms (In-Networking Providers)

  • EDI 835 ERA (Electronic Remit) Enrollment Form To receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier through a clearinghouse, you must first complete and submit the Virginia Premier ERA Enrollment form. Download PDF form.
  • Electronic Funds Transmission (EFT) Authorization Form If you are a participating provider and would like to authorize Virginia Premier to deposit payments directly into your banking account, please complete the EFT Authorization Form. You must include a W-9 form for proper processing.
  • Electronic Funds Transmission (EFT) Change Form If you are a participating provider and would like to authorize changes to how Virginia Premier deposits payments directly into your banking account, please complete the EFT Change Form. You must include a W-9 form for proper processing.
  • W9 Completed form must be included with electronic funds transfer forms for processing.
  • Claim Adjustment Form Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form.
  • Provider Refund Form The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.

ARTS Provider Attestation Forms

ASAM 2.1 – 3.7 Attestation

ARTS OBOT Attestation

ARTS OTP Attestation

Claims and EDI Forms (Out-of-Network Providers)

Contracting and Credentialing Forms (In-Networking Providers)

  • Provider Update Request Form Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier.
  • Panel Change Request Form Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.

Contracting and Credentialing Forms (Out-of-Network Providers)

  • Recruitment Request Form Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out Recruitment Request form to request participation in the Virginia Premier network.
  • Transportation Recruitment Request Form Complete this form when requesting a vendor to be recruited, or when receiving a call from an interested vendor.
  • Provider Update Request Form Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier.
  • Panel Change Request Form Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
  • Medical Management

    Pharmacy Forms

    Formulary

    Medallion 3.0 and FAMIS Members