Forms

Waiver of Liability Form (PDF)
Non-contracted providers have the right to file a standard appeal in order to dispute a payment or to appeal a denied claim. To do so you must complete a waiver of liability statement in which you formally agree to waive any right to payment from the enrollee regardless of the outcome of the appeal.

Provider Data Form
(PDF)

Senior Whole Health's standard individual practitioner credentialing form. To be submitted by each new practitioner.

Federally Required Disclosures (PDF)

Standard Provider Information Change Form (PDF from HCASMA.org) 
This form is to be used when you are changing your practice name, address, phone/fax numbers, email, billing details or other demographic information. The Standard Provider Information Change Form should not be used to submit credentialing or contractual changes.

Provider Interest Form (PDF)
Non physician providers may submit a completed interest form for consideration to join the Senior Whole Health network. Senior Whole Health will contact you should there be a network need for the services you provide.

Provider Interest Form for Home Health Providers (PDF)
Home Health Aid providers may submit a completed interest form for consideration to join the Senior Whole Health network. Senior Whole Health will contact you should there be a network need for the services you provide.

W-9 Form (PDF from IRS.gov)
TIN request form to be submitted with Provider Data Form.

PCP Assessment Form (PDF)

To be completed by PCP (or his/her proxy when signed by the PCP) when a patient becomes a Senior Whole Health member. Senior Whole Health provides reimbursement upon completed form receipt. A printout of the patient's EMR may be submitted in place of form.

2017 Standardized Prior Authorization Request Form (PDF) 
The New Standardized Prior Authorization Request Form should be used beginning on or before January 1, 2017. Please click here for important information including fax numbers.

Nutritional Authorization Form (PDF)

Home Health Authorization Form (PDF)

To be used for authorization of home health services.

Payment Dispute and Adjustment Request Form (PDF)

To be used when seeking adjustment for claims in specific circumstances. Please refer to the Provider Manual for more information.

PCP-NP Enrollment Form (PDF)

To be used to enroll NPs as PCPs. Please refer to the Provider Manual for more information.

Rehab/Chronic/SNF/Referrals Form (PDF)

SNF — Request for SWH Review (PDF)

Online Request for Medicare Part D Prescription Drug Coverage Determination

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in English

Online Request for Medicare Part D Redetermination

First Tier, Downstream, and Related Entities (FDR) Compliance Guide & Attestation: Click here to review and complete the FDR Annual Compliance Attestation


Last Updated 02/09/2018