Agreement For Participation Template - Department Of Vermont Health Access
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4AGREEMENT FOR PARTICIPATION
Naturopathic Physician
Department of Vermont Health Access
Primary Care Case Management Program (Primary Care Plus)
312 Hurricane Lane, Ste 201
Williston, Vermont 05495
Complete this form and return to:
HP Enterprise Services
Provider Relations
PO Box 888
Williston, VT 05495
Thank you for your interest in DVHA’s Primary Care Case Management Program serving Vermonters throughout the State.
PRACTICE INFORMATION (Name of group practicing with if applicable)
Name of Practice: _________________________________________________________
Address: ________________________________________________________________
City, State, Zip Code: ______________________________________________________
Tax ID/SSN: _______________________ Practice Medicaid ID #: __________________
(Whichever is used to file with the IRS)
Provider Name: ________________________ Provider Number: ___________________
List the person in your practice who should be contacted by our office regarding DVHA PCCM members:
Contact Person: _____________________ Title: _________________________ Phone: ______________
Office Phone #:______________________ After Hours Phone #:_____________________
AGREEMENT
For the purposes of this agreement, a PCP (Primary Care Provider) refers to a licensed provider eligible to serve
as a PCP who has signed an agreement to participate in the program.
A. The following specifies the responsibilities of the Department of Vermont Health Access (DVHA).
1. In addition to service fees, DVHA will pay a case management fee to each PCP of $2.50 per month for
each PCCM beneficiary enrolled with that PCP on the first day of the month.
2. DVHA, through its fiscal intermediary HP Enterprise Services, will distribute a monthly roster of
beneficiaries enrolled with each PCP.
3. DVHA will provide education and member services functions for beneficiaries enrolled in the PCCM
program.
2-6-2012
Page 1
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