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Forms Library

Our forms library below is where Virginia Premier providers can find the forms and documents they need. Just click the titles of form and document types below:
  • 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

  • EDI 837 (Electronic) Claims Enrollment Form
    In order to submit your claims electronically through a clearinghouse, you must first complete and submit the Virginia Premier EDI 837 Claims Enrollment form. Download PDF form.
  • 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.
  • 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.
  • 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.

Formulary

Medallion Members

Commonly Used Coverage Determination Forms
Drug/Disease Specific Specialty Drug Order Forms
General Specialty Drug Order Forms
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