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 of New York's standard individual practitioner credentialing form to be submitted by each new practitioner.

W-9 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 member. Senior Whole Health of New York provides reimbursement upon completed form receipt. A printout of the patient's EMR may be submitted in place of form.

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.

Online Request for Medicare Part D Prescription Drug Coverage Determination

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) for Senior Whole Health of New York NHC (HMO SNP) Plan

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) for SWH Whole Health FIDA Plan

Online Request for Medicare Part D Redetermination

Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF) for Senior Whole Health of New York NHC (HMO SNP) Plan

Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF) for SWH Whole Health FIDA Plan

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



Last Updated 02/06/2018