Providers & ASAPs

Let us contact you about what Senior Whole Health can do for you today. It's simple & easy!

Provider Forms and Resources

To download the forms and resources, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.

Member Benefit Coverage

2012 Summary of Benefits (PDF)

Provider Forms

Provider Data Form (PDF)
SWH's standard individual practitioner credentialing form. To be submitted by each new practitioner.

W-9 Form Provider Data Form (PDF from IRS.gov)
TIN request form 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 SWH member. SWH provides reimbursement upon completed form receipt. A printout of the patient’s EMR may be submitted in place of form.

Authorization Form (PDF)
To be used to submit requests for authorization by non-participating providers and by participating providers whose services require authorization.

Eligibility Confirmation Fax Form (PDF)
Form to be used to submit eligibility confirmation requests via fax.

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.