Providers Portal

Online Provider FormsForms

Texas Provider Forms (TVHP)
-TVHP Adding or Opening an Office Form (PDF)
-TVHP Claim Appeal Request Form (PDF)
-TVHP Closing an Office Form (PDF)
-TVHP Community First Marketplace Frame Formulary (PDF)
-TVHP Disclosure of Ownership and Control Interest Statement (PDF)
-TVHP Fax Cover Sheet for Claims Attachment (PDF)
-TVHP Medical Management Prior Notification Request Form (PDF)
-TVHP Non-Covered Service Liability Acknowledgement Form (PDF)
-TVHP Office Relocation Form (PDF)
-TVHP Pre-Authorization Request for UnitedHealthCare (PDF)
-TVHP Prior Authorization Request for Superior (PDF)
-TVHP Provider Address Form (PDF)
-TVHP Statement of Controlled Substance Coverage Form (PDF)
-TVHP Suspended Status Acknowledgement Form (PDF)
-TVHP Vision Care Eyeglass Patient Certification for Texas (PDF)
All State Providers
-Adding or Opening an Office Form (PDF)
-Advanced Beneficiary Notice (ABN) (PDF)
-All States Provider Address Form (PDF)
-All States W-9 (PDF)
-California Health & Wellness Replacement Frames Acknowledgement (PDF)
-Claims Appeal Request Form (PDF)
-Closing an Office Form (PDF)
-Electronic Funds Transfer Form (PDF)
-Fax Cover Sheet for Claim Attachments (PDF)
-Marketplace Frame Formulary (PDF)
-Non-Covered Services Liability Acknowledgement (PDF)
-Office Relocation Form (PDF)
-On-Line Access Request (Link)
-Ownership and Control Disclosures Form (PDF)
-Panel Participation Request Form (PDF)
-Pre-Authorization Request Form (PDF)
-Pre-Authorization Request for California Health & Wellness Members (PDF)
-Pre-Authorization Request for CeltiCare (PDF)
-Pre-Authorization Request for Coordinated Care Members (PDF)
-Pre-Authorization Request for Home State Health Plan Members (PDF)
-Pre-Authorization Request for Louisiana Healthcare Connections Members (PDF)
-Prior Notification Form (PDF)
-Replacement Eyewear Acknowledgement (PDF)
-Statement of Controlled Substance Coverage (PDF)
-Suspended Status Acknowledgement Form (PDF)
-UPMC Health Plan Non-Covered Services Agreement (PDF)
-Waiver of Liability Form (PDF)
Kansas Provider Forms
-Claims Appeal Request Form for KanCare Members (PDF)
-Kansas Ownership and Control Disclosures Form (PDF)
-Pre-Authorization Request for Sunflower Health Plan (PDF)
-Pre-Authorization Request for UnitedHealthcare Community Plan of Kansas (PDF)
New Hampshire Provider Forms (New Hampshire Healthy Families)
-New Hampshire Healthy Families Adding or Opening an Office Form (PDF)
-New Hampshire Healthy Families Closing an Office Form (PDF)
-New Hampshire Healthy Families Members Pre-Authorization Form (PDF)
-New Hampshire Healthy Families Office Relocation Form (PDF)
-New Hampshire Healthy Families Ownership and Controls Disclosure Form (PDF)
-New Hampshire Healthy Families Provider Address Form (PDF)

Submission of credentialing materials does not guarantee the processing or approval of your participation with OptiCare Managed Vision / TVHP-Total Vision Health Plan of Texas, Inc. All submitted materials will be reviewed and responded to accordingly.

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