Virginia Premier Health Plan, Inc.

Provider Forms

Provider Recruitment Form
Register to become a participating provider.

Virginia Premier Provider Application Form
Download our printable provider application form to apply to become a provider for Virginia Premier Health Plan coverage.

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

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 Group Change 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.

Electronic Funds Transmission Authorization Form
Use this form to authorize Virginia Premier Health Plan, Inc. to deposit any information owed to you.

Electronic Funds Transmission (EFT) Change Form
Use this form to change information in your electronic Funds Transmission Authorization Form.

CareLink User Form
Use this form to gain access to the CareLink provider portal.  Please have each person that will be using the system complete a form.

CareLink User Manual
This is a comprehensive guide to using our online provider portal (CareLink).

How to read PDF files

In order to download and view PDF files, you should download the free Adobe Acrobat Reader and install it on your computer.