Provider Resources tcdadmin August 24, 2024
Provider Forms and Resources

Vivant Health is committed to assisting network providers with process improvement support. The resources and forms on this page are among those most requested by our providers and are here for your convenience. Not all of these are created by Vivant Health, and we are not responsible for the content on external sites and forms that you may find here. If you have suggestions for this page, please feel free to mention them to your Vivant Health Provider Services Representative.

Forms and Resources

Authorization form (paper version)


BC Member termination form


Vivant Health EFT form


Vivant Health ACH Form

Care Management Referral Form

Notice of pregnancy


Infant Nutrition, Therapeutic Formula Authorization form


Vivant Health member relations referral form


Social work referral form


CCS program eligibility (link leads to DHCS web site)


GeneDx test requisition form


Provider Dispute Resolution form (PDR)

SFTP Request Form

Guidelines for Compliance and Monitoring

ERA Enrollment Form

Claim Settlement and Dispute Resolution Practices 


Electronic Claims & Remittance

Advanced Medical Management MSO

Health Net HEDIS Quick Reference Guide
HEDIS 2024 Medicare Tip Sheets

Guide for working the gaps in care

HEDIS 2024 Overview Packet

Contracting Request Form
CAQH – Physician Application (MD, DO, DPM, OD, PT, RD, DC, etc…)
Non-CAQH – Physician Application (MD, DO, DPM, OD, PT, RD, DC, etc…)
CAQH – Midlevel Application (NP, PA, CRNA, Midwife, etc…)
Non-CAQH – Midlevel Application (NP, PA, CRNA, Midwife, etc…)

Vivant Guidelines for Compliance and Monitoring

Claims and EDI

At Vivant Health, we work hard to simplify the claims process. This is for our network providers and those in Vivant Health care management programs. We offer comprehensive services and resources. We utilize EDI for claims management. This ensures a smooth and efficient experience for healthcare providers.

Learn More

Please Reach Out to Our Support Team for Any Assistance

Vivant Health’s approach is designed to support all your clinical care and administrative needs. Our dedicated provider relations team, as well as other provider support program staff, work to add value back into your practice by actively assisting you with any challenges or questions. We encourage our providers to utilize these resources to ensure smooth operations and achieve the best outcomes for our shared patient populations.

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