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
Forms for New Providers
Join Our Provider Network
Forms for Current Providers
CDPAS Recertification – Physician Order Form
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.
Demographic Update Form
EFT Request Form
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
Transitional Concurrent Care Coverage Request Form
Transitional Concurrent Care (TCC) helps patients smoothly transition to hospice care. It includes curative treatments, for up to 60 days, after choosing hospice care with an in-network provider, and is coordinated between the TCC provider, hospice team, and the VNS Health care team, as applicable.