Agreement For Participation Template - Department Of Vermont Health Access Page 4
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4We the undersigned agree to the requirements set out in this agreement.
Please make payment to: ___ the PCP, ___ the Practice
Signature Section:
Provider Signature:
Name: ______________________________________
Title: ____________________________+
Signature: ___________________________________
Date: ________________
DVHA Signature:
Name: ______________________________________
Title: ____________________________+
Signature: ___________________________________
Date: ________________
*****************************************************************************************
Please complete the below section and provide all information specific to the provider requesting to participate
in Vermont’s Primary Care Plus Program*. DVHA currently allows physicians and nurse practitioners to be
chosen as a Primary Care Provider.
Provider Name: ________________________________________________________________
Physician: _______________________ or Nurse Practitioner: ___________________________
Medicaid Provider #:_____________________ State License #:__________________________
Specialty: _________________________________________
Physician's Office Hours: Sun ______ Mon ______Tue ______ Wed ______ Thu ______ Fri ______ Sat ______
Total Hours: ___________
Accepting New Patients: _____ YES _____NO
____ Accept children (0-12) ____ Accept Adolescents (ages 13-20) ____ Accept Adults (ages 21+)
Practice Site Street Address _______________________________________________________
City: _______________________________ State: _______________ Zip code: _____________
An Individual not currently enrolled as a Vermont Medicaid provider wishing to participate in Vermont’s Primary Care
Plus program, must also complete the Provider Enrollment Agreement and receive a Medicaid provider number before the
PCP agreement can go into effect. The Vermont Medicaid Provider Enrollment Agreement can be downloaded from the
Vermont Medicaid website at , for questions please call HP Enterprise
Services Provider Relations at (802) 878-7871.
8-1-2012
Page 4
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