Versant Health Provider Add Form

Provider Add Form

This form used to add a new location for an in-network Eye Care Professional or to add an in-network Eye Care Professional to and existing office. Please note credentialing is required for each Davis Vision and Superior Vision on the practitioner level, not office level. A completed W-9, ADA Attestation Form and Disclosure of Ownership Form are required for each new office location.
Request for the following networks *

Davis VisionSuperior VisionBoth Davis Vision and Superior Vision
Reason for Submission - If New Location - Please complete ADA and DOO forms below*

Add Credentialed Practitioner to New Location on our network(s)Add Credentialed Practitioner to Existing Location on our network(s)Add New Dispense Only Location (Versant Health does not credential opticians)
Disclaimer:

For adding new dispense only location(s) onto the network(s), if an agreement has not already been established, the office will be directed to complete an Onboarding Form.
Please enter name of Retailer if affiliated:
*Walmart, Costco, Target ect.
Needing to Add Multiple Credentialed Practitioners?*

YesNo
Number of Credentialed Practitioners Needing to be Added*
Plan Types

All Health PlansMedicareMedicaidAll Plans excluding Medicare/Medicaid
Practitioner Information

This form will only apply to one practitioner on the Versant Health Network
Practitioner Full Name*

First NameLast Name
Individual NPI*
To add additional credentialed practitioners to this office, list the practitioner's full name and NPI below. For offices with more than five practitioners, the processing time may take longer than 30 business days.
Office Information

This form may be utilized for multiple office location(s) This portion will be used in conjunction with the information found on the ADA and DOO forms for each new office location.
Owner of your own practice and/or in the process of purchasing an existing VersantHealth Vision practice?

YesNo
Disclaimer:

For each additional office location(s), separate Provider Add Form(s) will be required.
Office Name*
DBA Office Name*
Office ID
Note: For Existing Offices: Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s).
Office Address*
City*
State*
Zip*
Disclaimer: If adding a credentialed practitioner to a location in a different state, an agreement may be required.
Office Contact Name*

First NameLast Name
Office Contact Email*
Will be used for this request
Office Contact Phone Number*
Please enter a valid phone number.
Tax Identification Number*
Location NPI

Languages Spoken at location

American Sign LanguageEnglishSpanishOther
Add Service Types

Routine ExamEyewear DispensedContact Lens FittingContacts DispensedMedical ExamsMedical/SurgicalPediatric ServicesOther
Are these service(s) affiliated with a retailer or optical location?

YesNo
Location Medicaid and Medicare ID(s)

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

To update the location Medicaid and/or Medicare ID after an initial credentialing application has been submitted, submit the Provider change form and attach a copy of the state approval letter(s).
Location Medicaid ID
This location must be registered with the state to be added to Medicaid plans
Location Medicare ID
This location must be registered with the state to be added to Medicare plans
Does this location carry a Versant Health Exclusive Frame Collection?*

YesNo
Exclusive Frame Collection Housing Options:
Please make your selection carefully - will be shipped to the address below
Shipping Address

If different than office address
Shipping Address
City
State
Zip
Additional Office Locations:

Note For Exisiting Offices: Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s).
Input a 1 then consecutive numbers fore each office not currently on the network
Additional Office Location(s)*
Office Information*
Office Contact Information*
Office Service Type(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 - if different than location 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?*
For more information about Federally Qualified Health Centers, please visit https://www.fqhc.org/find-an-fqhc.
Is this office in the New Jersey Maps Program?*

YesNo
Are any of the office(s) a New Jersey Maps Program?*
Would you also like to update the Davis Vision or Superior Vision Network?

YesNo, I'm not interestedNo, I'm already a part of the entity and network
W-9 Form*

Cancelof
W-9 Form(s)*

Cancelof
Save, complete and upload the following document(s):
*New Jersey Providers must complete all attestation forms.
Versant Health Federal Disclosure of Ownership
Versant Health Federal Disclosure of Ownership Submission*

Required for all providers and offices.
Cancelof
Versant Health Americans with Disabilites Act Provider Attestation
Versant Health American with Disabilities Act Attestation Submission*

Required for all providers.
Cancelof
Versant Health *New Jersey Aged, Blind and Disabled Attestation
Versant Health *New Jersey Aged, Blind and Disabled Provider Attestation Submission

*Requred for New Jersey providers only.
Cancelof
Versant Health *New Jersey Criminal Background Check Attestation
Versant Health *New Jersey Criminal Background Check Attestation Submission

*Requred for New Jersey providers only.
Cancelof
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.
Cancelof
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.
Signer Name*

First NameLast Name
Additional Information
*Versant Health Use Only
Exclusive Collection

YesNo, not participating in MedicaidNo, carrying Exclusive Collection
Contract Type
Plans to be Mapped
REIM

	Open	Close
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Available After hours Y/N

Provider Add Form

Practitioner Information

Office Information

Disclaimer: If adding a credentialed practitioner to a location in a different state, an agreement may be required.

Shipping Address

*Versant Health Use Only

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