Are you a Provider and looking for a specific CompleteCare form? Find forms quickly in our Provider Forms Library by either searching by the type of form you need or feel free to view our entire forms library below.

Claims and EDI Forms

  • EDI 837 (Electronic) Claims Enrollment Form (CompleteCare) In order to submit your claims electronically through a clearinghouse, you must first complete and submit the CompleteCare EDI Enrollment form.
  • W9 A completed W9 form should be sent for any legal name changes or Tax Identification Number Changes.
  • Claim Adjustment Form Providers who want to appeal a claim outcome, submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form.
  • Provider Refund Form The Provider Refund Form will assist Virginia Premier 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.

Contracting and Credentialing Forms

  • Recruitment Request Form Are you a physician or healthcare provider interested in joining the Virginia Premier network? Please fill out Recruitment Request form to request participation in the Virginia Premier network.
  • Transportation Recruitment Request Form Complete this form when requesting a vendor to be recruited, or when receiving a call from an interested vendor.
  • Provider Update Request Form Are you already a participating provider for Virginia Premier and need to notify us for updates or changes to your office or provider information such as address, phone or providers? Please use this page to submit changes to Virginia Premier.
  • Panel Change Request Form Are you a participating PCP and would like to close or open your member panel? Please use this form to notify Virginia Premier of your request.
  • Organizational Enrollment Application Form Download our organizational enrollment packet and application.

Medical Management

Pharmacy Forms