Versant Health Provider Change Form

Provider Change Form
Request changes to the following network(s)*

Davis VisionSuperior VisionBoth Davis Vision and Superior Vision
Date of Request*

MonthDayYear
Date
Requestor Name*

First NameLast Name
Requestor Phone Number*
Please enter a valid phone number.
Requestor Email*
example@example.com
Effective Date of Change*

MonthDayYear
For ownership changes of an existing practice, please enter a future date
Reason for Request
Select one - *unselect all to reset*

Change Office Demographic Information (Name, Hours, Contact, Addresses)Practitioner Name ChangeRemove Panel/PlanChange Network Status to No New Patients (NNP)Change Tax Identification Number *(W-9 Form required)Sell of Practice/Ownership Change *(W-9 and Bill of Sale required)Add Medicaid/Medicare LOB *(State Approval Letter with ID and address required)Remove from MedicaidRemove from MedicareChange Services (ex. exam, dispense)
Does this practice currently have the Exclusive Frame Collection?*

YesNo
Member ID Member ID* Name of Panel/Plan Panel or Plan*
Current Office Information
Davis Vision and/or Superior Vision Office Number*
Separate multiple offices with commas. Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s).
Current Office Name*
Current Office Address
Current Street Address *
Current City*
Current State*
Current Zip Code*
Current Contact Information

Phone NumberFax Number
Current Office Phone Number
Please enter a valid phone number.
Current Office Email
example@example.com
Current Tax Identification Number*
Practitioner Information
Practitioner Name*

First NameLast Name
Practitioner NPI*
New Office Information
Update Office Information
New Office name
New Physical/Directory Address
Physical Address City
Physical Address State
Physical Address Zip
New Contact Information*

Phone NumberFax Number
New Office Email
example@example.com
New Tax Identification Number*
Please enter a valid Tax ID Number and upload copy of W9*.
Update Billing Address Information

** Must provide W-9 with new address and current Tax Id Number
New Billing Name
New Billing Address
Billing Address City
Billing Address State
Billing Address Zip
Update Shipping Address Information
New Shipping Address
Shipping Address City
Shipping Address State
Shipping Address Zip
Does this location offer telehealth services?*

YesNo

Medicaid/Medicare Information

Medicaid Number Pending Medicaid IDs cannot be approved to add Medicaid Plans. Locations must be registered with the state.Medicare Number Pending Medicaid IDs cannot be approved to add Medicaid Plans. Locations must be registered with the state.
New Practitioner Name

First NameLast Name
Practitioner NPI
Panel/Plan
Enter the name of panel if known
Change Network Status to No New Patients (NNP)
Update Service Type

Routine ExamEyewear DispensedContact Lens FittingContacts DispensedMedical ExamsMedical/SurgicalPediatric ServicesTelehealthOther
Member ID
Enter Member ID to ensure correct plan
W-9 Form and/or Bill of Sale

Bill of Sale is required for change of ownership
Cancelof
Medicaid and/or Medicare State Approvals

State Approval Letter with ID and address are required
Cancelof
Signature*

Clear
Authorized Signer Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

	Open Time	Closed Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Provider Change Form

Reason for Request

Current Office Information

Current Office Address

Practitioner Information

New Office Information

Update Office Information

Update Billing Address Information

Update Shipping Address Information