SV Network Development Onboarding Form Draft

Provider Onboarding Form
This form will be utilized in the eyecare professional's official application.
Reason for Submission*
Add New Practitioner and New LocationAdd New Practitioner to Existing LocationAdd Credentialed Practitioner to New LocationAdd Credentialed Practitioner to Existing LocationAdd Plan(s)
Plan Types*
All Health PlansMedicareMedicaidInsurance through Employer
Adding at least 10 practitioners and/or locations at one time?*
YesNo
By selecting yes, the user will be redirected to complete a Group Roster Form.
Submissions that do not meet the 10+ practitioner and/or location requirement will not be processed.
Practitioner Information
This application form will only apply to one practitioner joining the Davis Vision Network
Practitioner Full Name*
First NameLast Name
Individual NPI*
Profession*
ODMDDOOptician
Specialty
Gender*
MaleFemaleN/A
Ethnicity *
DOB*
MonthDayYear
Social Security Number*
CAQH Number*
*A CAQH Application is required of all practitioners
Individual Medicaid ID*
Input N/A if not participating in Medicaid
Individual Medicare ID*
Input N/A if not participating in Medicare
Adding Multiple Practitioners?*
YesNo
Number of Practitioners Needing to be Credentialed*
For practices with 10+ eyecare professionals and/or locations, you will be redirected to complete a Group Roster Form. *Do not complete this form for every practitioner and/or location if the roster applies. *Submissions that do not meet the 10+ practitioner and/or location requirement will not be processed.
Office Information
This application form will only apply to one practitioner joining the Superior Vision Network This application form may be utilized for mulitple office location(s)
Owner of your own practice and/or in the process of purchasing an existing Superior Vision practice?*
YesNo
If an eyecare professional has recently purchased an existing Superior Vision practice, a Bill of Sale, W-9 Form and Provider Change Form will be requested and is required to update our systems.
Primary Office Name*
DBA Office Name
Primary Office Location*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Adding the practitioner to multiple offices? If yes, select the + button below and number each additional location accordingly.
Additional Office Location(s)*
Note: For Exisiting Offices: Utilize the location field on the Eyecare Professional Portal to find the Provider/Office ID(s).
Input N/A if the office is not currently on the network
For Exisiting Offices: complete the following*
Office Information*
Office Contact Information*
Office Service Type(s)*
As an In-Network provider, you may receive the Exclusive Collection, an additional 222 or 48 frames to your existing selection. A display of top-selling eyewear offered to members for low-to-no out-of-pocket cost. Non-members may also select these frames at your own determined price. Materials Shipping Address:*
Are any of the office(s) a Federally Qualified Health Center?*
Attach Encounter Rate Approval Notice
For multiple office location(s), ensure an approval notice is included for all locations. Include if encounter rates are inclusive of vision, medical and/or materials.
Cancelof
For more information about Federally Qualified Health Centers, please visit https://www.fqhc.org/find-an-fqhc.
Are any of the office(s) a New Jersey Maps Program?*
Are any of the office(s) affiliated with a retailer? If yes, input a retailer code below*
Would you also like to join the Davis Vision Network?*
YesNo, I'm not interestedNo, I'm already a part of the network
Signature*
Clear
Attestation: I understand and acknowledge that neither the submission of a completed Versant Health, Provider Application nor the execution of a Versant Health Participating Provider Agreement constitutes acceptance as a Versant Health Participating Provider. Acceptance as a Versant Health Participating Provider is contingent on the acceptance by Versant Health of an applicant’s completed Application, and on the execution by the applicant of a Versant Health Participating Provider Agreement, and on the receipt by the applicant of the forms, manual and samples required for participation. Versant Health reserves the absolute right to determine which applicant is acceptable for participation and in which groups an applicant will participate.
Signer Name*
First NameLast Name
Nomination Code
Retailer Code
Additional Information
*Versant Health Use Only
Plans to be mapped: Superior National Superior Select Superior Select Health Plan(s) Health Plan(s) Health Plan(s) Health Plan(s)
Contract Type
Lab Usage
Should be Empty:

Provider Onboarding Form

Practitioner Information

Office Information

*Versant Health Use Only