Comprehensive Listing of Common Forms Needed by MVP Providers
From prior authorization and provider change forms to claim adjustments, MVP offers a complete toolkit of resources for our providers.
Provider Demographic Change Forms (All Regions)
- Provider Change of Information Form
- Using the Provider Change of Information Form
- Facility/Ancillary Provider Change of Information
- Provider Participation Guide
- Provider Application Request
To properly use the Provider Application Request Form, please right-click the link and select “Save link as” to save the file to your device. Then the form can be populated in Acrobat Reader. Do not complete this form in your browser.
- Supplemental Provider Credentialing Application
- MVP Contracted Hospitals
- Practitioner Continuity of Care Statement
- Provider Leave of Absence Notification
- Provider Credentialing Rights
- Federal Tax W-9
EDI Forms and Guides
For questions, contact our EDI Service Department by email or at 1-877-461-4911.
Claim and Risk Adjustment Forms
To learn about claim adjustment requests, review the Summary of CARF Enhancement presentation, which reviews claims adjustment requests that can be submitted and tracked online
Admissions and Prior Authorizations
Notification of Unplanned, Urgent, or Emergency Room Admission
- Prior Authorization Request Form (PDF)
- Prior Authorization Request Form (NY) (Sign-In Required)
- Prior Authorization Request Form (VT) (PDF)
- Prior Authorization Request Form for DME/O&P Items & Services (PDF)
- Prior Authorization Request Form for DME/O&P Items and Services (NY) (Sign-In Required)
- Prior Authorization Request Form for Skilled Nursing Facilities & Acute Inpatient Rehabilitation (SNF & AIR) (PDF)
Reminder: For a more streamlined review process, log in to your MVP provider online account and submit pharmacy prior authorization forms via Novologix.
- NYS Medicaid Prior Authorization Request Form for Prescriptions (PDF)
- Prior Authorization Request Form for Medication (PDF)
- Medication (General & Formulary exception) (Sign-in required)
Medicare Part D
- Hospice — Medicare Part D (PDF)
- Medicare Prescription Drug Coverage Determination Request (Submit Online)
- Medicare Standard Form (PDF)
Radiation and Radiation Therapy
- Information about eligibility and prior authorization can be found at eviCore healthcare.
Personal Care Services
- Personal Care Services Time-Tasking Tool (Digital Version) (PDF). If you are using the digital version, please right-click the link and select Save link as to save the file to your device. Do not complete this form in your browser.
- Personal Care Services Time-Tasking Tool (Print Version) (PDF)
- Considerations for Personal Care Services (PDF)
- ABA Authorization Request (PDF) For requesting authorization for Applied Behavioral Analysis Assessment and Treatment
- Authorization to Disclose Information (PDF) For Members to complete if they wish to give MVP permission to discuss their health with another person
- Substance Use Disorder Two Business Day Notification and Initial Treatment Plan (PDF) For use by hospitals and facilities when a member is admitted for Inpatient and/or Residential Substance Use Treatment
- Two-Day Notification and Initial Treatment Plan (PDF) For use by hospitals and facilities when a child/adolescent, age 0-17, is admitted for Inpatient Mental Health
- Mental Health Treatment Notification of Admission (PDF) For use by hospitals and facilities when an adult, age 18+, is admitted for Inpatient Mental Health and for admissions to Mental Health Residential Treatment Centers for members of all ages
- Behavioral Health Outpatient Treatment Request (PDF) For use by Providers requesting authorization for outpatient mental health and/or substance use treatment
- Prior Authorization Request Form (VT) (PDF) For use by Providers located in VT requesting authorization for mental health and/or substance use treatment
- Children’s Home and Community Based Service Notification Form For use by Children Home and Community Based Service providers when requesting an initial HCBS service request for children.
- Children’s Home and Community Based Services Authorization Continuation Form (NYS) For use by Children Home and Community Based Service providers when requesting continued authorization for HCBS for children
- Primary Care Provider Change or Patient Reassignment Request (PDF)
- Disability Eligibility Determination Form (PDF)
- Member Approval for Appeal Delegation Form (PDF)
- Diabetic Eye Exam Form (PDF)
- Diabetic Eye Exam Form-Spanish (PDF)
- Unclaimed Property Claim Form (PDF)
- New York Health Care Proxy
- Vermont Health Care Proxy
- Medical Orders for Life Sustaining Treatment (MOLST) (PDF)
- Disclosure of Ownership-Control (Facilities) (PDF)
- Disclosure of Ownership-Control (Provider Group) (PDF)
- Disclosure of Ownership-Control FAQs (Provider Group) (PDF)
- Unclaimed Property Claim Form (PDF)
Un-cashed Checks? Please visit LongLostMoney’s website to see if MVP has any un-cashed checks in your name, or in the name of your business.