Virginia Premier Health Plan, Inc.

Provider Forms

Provider Refund Form
The Provider Refund Form will assist with handling your refund inquiries expeditiously.  Please ensure all fields on the form are completed along with attached detailed information explaining the reason for the refund.  This will ensure a faster turnaround time on your refund request.

Recruitment Request Form
Download our printable provider form to apply to become a provider for Virginia Premier Health Plan coverage.

Organizational Enrollment Application Form
Download our printable oranizational enrollment application form.

Children Special Health Care Needs Provider Assessment Tool
Use this form to indicate whether you render services to Children with Special Health Care Needs.

National Provider Identification Number (NPI) Submission Form
Register your NPI with us using our online registration form and help ensure a seamless conversion to the NPI system. You can also download the submission form in PDF format for printing and manual submission.

Provider Update Request Form
If you are already a provider for Virginia Premier and need to notify us for updates or changes with your provider or group information, download the printable PDF form above.

Panel Change Request Form
Use this form to notify us of changes with the PCP's panel.

PCP Change Request Form
Use this form to notify us of changes with the member's PCP.

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 Form 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 Form for processing.

For Authorization and Referral Forms please click here.

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