Versant Health Network Development Onboarding Form

Review your answers prior to submitting

After completing this form, you will be required to review your answers. You must select the submit button after reviewing the answers provided. Without selecting the submit button, we will not receive this completed form.
Reason for Submission*

Add New Practitioner and New Location(s)Add New Practitioner to Existing Location(s)Add New Independent Optical onto the Network(s)Superior Vision Only: Add a Line of Business
Interested in joining all Versant Health Networks?*

Yes, I'm Interested in joining Davis Vision and Superior VisionNo, I'm only interested in joining Davis VisionNo, I'm only interested in joining Superior Vision
Needing to Credential Multiple Practitioners?*

YesNo
Number of Practitioners and/or Locations Needing to be Credentialed*
For practices with less than 10 eyecare professionals and/or locations, please complete an Onboarding Form for each practitioner and include all applicable service locations. For practices with 10+ eyecare professionals and/or locations, you will be redirected to complete a Group Roster Form. *Do not complete the Onboarding Form for every practitioner and/or location if the roster applies. *Submissions that do not meet the 10+ practitioner and/or location requirement will not be processed.
Versant Health Provider Onboarding Roster

Follow the link below to complete a Versant Health Provider Onboarding Roster
Versant Health Provider Onboarding Roster
Individual Onboarding Forms for each practitioner and location are no longer required when completing a Versant Health Group Roster.

Submissions that do not meet the 10+ practitioner and/or location requirement will not be processed and individual onboarding forms will need to be submitted.
Plan Types*

All Health PlansMedicareMedicaidInsurance through Employer

Practitioner Information
Practitioner Information

This onboarding form only applies to the practitioner provided above.
Practitioner Full Name*

First NameLast Name
Profession*

ODMDDOOptician
Specialty*
Individual NPI*
Does this practitioner have surgical privileges?

If yes, once an Onboarding Form has been completed, please complete a Versant Health Surgical Privileges Intake Form after the submission of this Versant Health Provider Onboarding Form.
Separate Onboarding Form(s) for each practitioner is still required.
A link will be provided after the submission of a Versant Health Provider Onboarding Form.
Gender*

FemaleMaleDo not wish to answer
Ethnicity
Ethnicity*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Opticians please input N/A.
CAQH*
A CAQH Application is required of all practitioners. For Washington state providers, you may also setup a OneHealthPort account.
Individual Medicaid ID*
Pending Medicaid IDs cannot be approved to add Medicaid Plans. Opticians please input N/A.
Individual Medicare ID*
Pending Medicare IDs cannot be approved to add Medicare Plans. Opticians please input N/A.
Medicaid and Medicare

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans¹. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, upload the state approval letter(s) and Provider Fee Schedule² by submitting a Provider Change Form³ located on the Provider Resource Center.

Valid Medicaid and/or a Medicare IDs are required for the practitioner to service Medicaid and/or Medicare plans.

^{1 For Ohio state providers, register with CVO. For Washington state providers, setup a OneHealthPort account. Opticians please input N/A.}^{2 Superior Vision Only. Will be provided after Onboarding submission.}
^{3 Required for Davis Vision and/or Superior Vision Network - Located on the Provider Resource Center}
Does this practitioner practice in New York?*

YesNo
*New York Medicaid Providers: Provide a copy of annual compliance certification (required)

Required for New York Medicaid Providers Only
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Practitioner's annual compliance certification(s) are a part of the Annual Certification of Statement for Provider Billing Medicaid Form. This certification is required to be submitted to eMedNY on the anniversary date of the provider’s enrollment in Medicaid.

Form sample here: eMedNY ETIN CERT FORM

Office Information
Office Information

This onboarding form only applies to the practitioner provided above. Please include all applicable service locations of the practitioner provided above.
Owner of your own practice and/or in the process of purchasing an existing Superior Vision practice?*

YesNo
If an existing Superior Vision practice has been purchased, a Bill of Sale, W-9 Form and Provider Change Form will be requested and is required to update our systems.
Adding the practitioner to multiple offices? If yes, select the + button below and number each additional location accordingly.*

YesNo
Primary Office Name*
DBA Office Name
Office ID*
Note: For Exisiting Offices: Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s). Input N/A if office location is not on the network
Office Location*

Street Address

Street Address Line 2

CityCounty

County
State*
Zip Code*
State
Input state abbreviation
State
Office Contact Name*

First NameLast Name
Office Contact Email*
This primary email recipient will receive email update(s).
Secondary Contact Email
You may include one (1) secondary email recipient to receive email update(s).
Office Contact Phone Number*
Please enter a valid phone number.
Phone Extension
Office Fax Number
Tax Identification Number*
W-9 Form*

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Location NPI*
Location Medicaid ID*
The location must be registered with the state
Location Medicare ID*
The location must be registered with the state
Medicaid and Medicare

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, upload the state approval letter(s) and Provider Fee Schedule¹ by submitting a Provider Change Form² located on the Provider Resource Center.

Valid Medicaid and/or a Medicare IDs are required for location(s) to service Medicaid and/or Medicare plans.

^{1 Superior Vision Only. Will be provided after Onboarding submission.}
^{2 Required for Davis Vision and/or Superior Vision Network - Located on the Provider Resource Center}
Location Service Type*

Routine Eye ExamsLow Vision ExamsContact Lens FittingDispense Contact Lenses and Eyewear OnlyDispense Contact LensesDispense Eyewear OnlyEyewear DispenseRxMedical Eye ExamsMedical SurgicalPost CataractLaser SurgeryRefractive SurgeryInjectionsAnesthesiaPediatric Services ProvidedMobileTelemedicineHome Visit(s)
Select Pediatric Age Group(s)*

Newborns (0 to 1 month)Infants (1 month to 12 months)Toddlers (1 to 3 years)Preschool age (4 to 5 years)School Age (6 to 12 years)Adolescents (13 to 17 years)Young Adults (18 to 21 years)
Mobile Unit Service Type(s)*

Routine Eye ExamsLow Vision ExamsContact Lens FittingDispense Contact Lenses and Eyewear OnlyDispense Contact Lenses OnlyDispense Eyewear OnlyEyewear DispenseRxMedical Eye ExamsMedical SurgicalPost CataractLaser SurgeryRefractive SurgeryInjectionsAnesthesiaPediatric Services ProvidedTelemedicineHome Visit(s)
Telemedicine Service Type(s)*

Routine Eye ExamsLow Vision ExamsContact Lens FittingDispense Contact Lenses and Eyewear OnlyDispense Contact Lenses OnlyDispense Eyewear OnlyEyewear DispenseRxMedical Eye ExamsMedical SurgicalPost CataractLaser SurgeryRefractive SurgeryInjectionsAnesthesiaPediatric Services ProvidedMobileHome Visit(s)
Home Visit Service Type(s)*

Routine Eye ExamsLow Vision ExamsContact Lens FittingDispense Contact Lenses and Eyewear OnlyDispense Contact Lenses OnlyDispense Eyewear OnlyEyewear DispenseRxMedical Eye ExamsMedical SurgicalPost CataractLaser SurgeryRefractive SurgeryInjectionsAnesthesiaPediatric Services ProvidedMobileTelemedicine
Exam / Optical Office Name*
Input exam / optical office name if separate entity. Enter "N/A" if not applicable.
Provider-Supplied Eyewear*
*Safety eyewear that is not affiliated with the Davis Vision Safety Collection
Does this location carry a Davis Vision Safety Frame Collection?*

YesNo
Does this location carry a Versant Health Exclusive Frame Collection?*

Yes, Davis Vision Exclusive Frame Collection (222 frames)Yes, Superior Vision Medicaid Collection (48 frames)No
Exclusive Frame Collection Housing Options:*
Please make your selection carefully
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code
Office Location(s)*
Note: For Exisiting Offices: Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s).
Input N/A if the office is not currently on the network
For Exisiting Offices: Complete the following*
Office Information*
Medicaid and Medicare

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, upload the state approval letter(s) and Provider Fee Schedule¹by submitting a Provider Change Form² located on the Provider Resource Center.

Valid Medicaid and/or a Medicare IDs are required for location(s) to service Medicaid and/or Medicare plans.

^{1 Superior Vision Only. Will be provided after Onboarding submission.}
^{2 Required for Davis Vision and/or Superior Vision Network - Located on the Provider Resource Center}
Office Contact Information*
Select Service Type(s) per Office Location*
For Pediatric Services Provided Select Age Group(s) (If applicable)
For Mobile Unit/Telemedicine/Home Visit(s), Select Service Type(s) (if applicable)
Separate Office(s)*
As an In-Network provider, you may receive the Exclusive Frame Collection, an additional 222 or 48 Medicaid frames to your existing selection. A display of top-selling eyewear offered to members for low-to-no out-of-pocket cost.
Subject to change based on demographics
Office(s) Shipping Address
Exclusive Frame Collection Housing Options:
Is this office a Federally Qualified Health Center?*

YesNo
Are any of the office(s) a Federally Qualified Health Center?*
Attach Encounter Rate Approval Notice

If you selected yes, this is required. For multiple office location(s), ensure an approval notice is included for all locations. Include if encounter rates are inclusive of vision, medical and/or materials.
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For more information about Federally Qualified Health Centers, please visit https://www.fqhc.org/find-an-fqhc.
Is this office an Indian Health Service or Tribal Health Service*

YesNo
Are any of the office(s) an Indian Health Service or Tribal Health Service*
Is this office in the New Jersey Maps Program?*

YesNo
Are any of the office(s) a New Jersey Maps Program?*
Is this office affiliate with a retailer? If yes, input retailer code below.*

YesNo
Are any of the office(s) affiliated with a retailer? If yes, input a retailer code below*
Retailer Code
Versant Health Forms

W-9, Americans with Disabilities Act (ADA), Disclosure of Ownership Forms Submission
W-9 Form(s)*

Required.
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Versant Health Americans with Disabilities Act (ADA) Attestation Forms (right click - save as, then complete and upload below)
Versant Health Americans with Disabilities Act (ADA) Attestation Forms Upload

Per location - if applicable
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Versant Health Disclosure of Ownership Forms (right click - save as, then complete and upload below)
Versant Health Disclosure of Ownership Forms Upload

Per entity and practitioner
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Confirmation
Signer Name*

First NameLast Name
Nomination Code
Credentialing Documents

Inclusive of Provider Fee Schedule, Participating Provider Agreement(s), ADA Attestation and Disclosure of Ownership. If not applicable, do not attach documentation.
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Signature*

Clear
Attestation: I understand and acknowledge that neither the submission of a completed Versant Health, Provider Application nor the execution of a Versant Health Participating Provider Agreement constitutes acceptance as a Versant Health Participating Provider. Acceptance as a Versant Health Participating Provider is contingent on the acceptance by Versant Health of an applicant’s completed Application, and onthe execution by the applicant of a Versant Health Participating Provider Agreement, and on the receipt by the applicant of the forms, manual and samples requiredfor participation. Versant Health reserves the absolute right to determine which applicant is acceptable for participation and in which groups an applicant will participate. Versant Health, Provider Application submission signifies your consent to receive important updates about your application progress via email.
Additional Information
Review your answers prior to submitting

After you select the review your answers button, you must select the submit button. Without selecting the submit button, we will not receive this completed form.

*Versant Health Use Only
*Versant Health Use Only
Exclusive Collection

YesNo, not participating in MedicaidNo, carrying Exclusive CollectionNo, not applicable
Contract Type
Plans to be Mapped
REIM
Lab Usage
Fee Schedule Type
Telemedicine
Mobile Clinic Capability
Should be Empty:

Review your answers prior to submitting

Versant Health Provider Onboarding Roster

Practitioner Information

Office Information

Versant Health Forms

Review your answers prior to submitting

*Versant Health Use Only