Virginia Premier Health Plan, Inc.

Claims Forms

• Claim Adjustment Form - Effective 2/28/2012
• W-9 Form
• Electronic Funds Transmission Authorization Form
  Use this form to authorize Virginia Premier Health Plan, Inc. to deposit any information owed to you. Must include a W-9 for processing.
• Electronic Funds Transmission (EFT) Change Form
  Use this form to change information in your electronic Funds Transmission Authorization Form. Must include a W-9 for processing.

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