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Forms

Provider Downloads

Inpatient-Outpatient Precertification Form
Provider Application Request Form
Provider Change of Information Form
Referral Authorization Form
Waiver of Liability Statement
W-9 Form
DME Precertification Request Form

HIPAA

VIVA's EDI Enrollment Form and Trading Partner Agreement.
VIVA's 837 Professional Companion Document
VIVA's 837 Institutional Companion Document

Pharmaceutical Forms and Lists

New Covered Preventive Services (11.30.2011)
2012 All Plan Formulary
2012 Coverage Determination Request (PA and Exceptions)
Medical Pharmacy Prior Authorization Form
2011 VIVA MEDICARE Plus Rx Formulary
2011 VIVA Medicare Plus Rx Premier Formulary
2011 VIVA Medicare Plus Rx Extra Value Formulary

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