Versant Health Provider Onboarding Roster

Versant Health Provider Onboarding Roster

Only applies to practices with 10+ eyecare professionals and/or locations
Services *

Wellness (Routine and Materials) Medical Surgical and Utilization Management

Office Information
Number of offices *
Input the number of service locations the practitioners will be linked to when credentialed onto the Davis Vision and/or Superior Vision Networks. Ensure you enter a record for each service location is included on the provided roster template.
Adding new office(s) onto the network(s)? *

Yes. An Americans with Disabilities Act (ADA) Provider Attestation Form and Federal Disclosure of Ownership Forms for each new location is required. See below under Versant Health Forms. No
For additional offices, select the + button below
Office(s) Name(s) *
Office(s) currently on the Davis Vision or Superior Vision Network(s)? *
Office Address *
Office(s) Service Type *
Office(s) Contact Information *
Office(s) Point of Contact(s) *
Office(s) Location NPIs and Tax Identification Numbers *
W-9 Form(s) *

Cancel of
Office(s) Group Medicaid and/or Medicare IDs *
Medicaid and/or Medicare Plans

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, visit the Provider Resource Center Forms Page to complete a Provider Change Form.

Valid Medicaid and/or a Medicare IDs are required for the practitioner to service Medicaid and/or Medicare plans.
Office(s) Affiliation with a Retailer *
Exclusive Collection of Frames

As an in-network provider¹, you may receive the Exclusive Collection which is inclusive of 222 frames or 48 Medicaid frames² to add to your existing selection. Showcased on a compact rotating fixture, a display of top-selling eyewear offered to members for low-to-no out-of-pocket cost. Can also be ordered to sell to your non-members at your own determined price.
¹Subject to change based on demographics.
2Superior Vision Providers
Office(s) Exclusive Collection Housing Option *
Office(s) Shipping Address *

Practitioner Information
Number of Practitioners *
Input the number of practitioners needing to be added or credentialed onto the Davis Vision and/or Superior Vision Networks. Ensure you enter a record for each practitioner at each office # (location).
For Additional Practitioners, select the + Button Below
Practitioner Information *
Practitioner Information *
Practitioner's will be added onto the Davis Vision or Superior Vision Networks? *
Practitioner Information *
Medicaid and/or Medicare Plans

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, visit the Provider Resource Center Forms Page to complete a Provider Change Form.

Valid Medicaid and/or a Medicare IDs are required for the practitioner to service Medicaid and/or Medicare plans.

Versant Health Forms
Versant Health Americans with Disabilities Act (ADA) Provider Attestation Form (right click - Save As)
Versant Health Americans with Disabilities Act (ADA) Provider Attestation Forms Forms Upload

Cancel of
Federal Disclosure of Ownership Forms (right click - Save As)
Federal Disclosure of Ownership Forms Upload

Cancel of
Are any of these locations 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.
Cancel of
Are any of these locations in the New Jersey Maps Program? *
Supplemental Credentialing Documentation

Inclusive of Superior Vision Provider Fee Schedule and/or Participating Provider Agreement(s). If not applicable, do not attach documentation.
Cancel of

Confirmation
Plan Types *

All Health Plans Medicare Medicaid Insurance through Employer
Retailer Code(s)
Nomination Code
Signature *

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. Clear
Signer Name *

First Name Last Name

*Versant Health Use Only
Exclusive Collection(s)
Contract Type

Group Individual
Plans to be mapped
Lab Usage
REIM
Fee Schedule Type
Should be Empty:

Versant Health Provider Onboarding Roster

For additional offices, select the + button below

For Additional Practitioners, select the + Button Below