Add New Location Form ADD A NEW LOCATION FORM Whether you move an EXISTING office across the street or open a NEW office, all new office locations must be reviewed to ensure they meet NVA criteria. NVA will not add a new location until it is approved by NVA Credentialing. Use this form to tell us about your new location. Use one form for each new location and allow NVA Credentialing 3-4 weeks to complete its review. If the location is approved NVA will notify you, add the location to the NVA roster for each doctor you list, and send the information to those plans in which each doctor participates through NVA. I am requesting that the office location described below be added to the NVA panel for the doctors listed.Signature(Required)Date:(Required) MM slash DD slash YYYY Name of Person Submitting Application:(Required) First Last Telephone Number for Person Submitting Application:(Required)Email Address for Person Submitting Application:(Required) NEW LOCATION INFORMATION:Practice Name:(Required)Tax ID #:(Required)NPI #:(Required)Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Date office opened:(Required) MM slash DD slash YYYY Phone:(Required)Fax:(Required)Email:(Required) Mailing Address (if different from above): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Names of Practice Owners:(Required)Is this location REPLACING another location? If so, please attach an NVA “PRACTICE CHANGE” form.(Required) Yes No Did any doctors at this new location leave ANOTHER location or practice to be at this NEW location? If so, please attach an NVA “REMOVE or ADD DOCTOR” form.(Required) Yes No Are frames, spectacle lenses, and contact lenses dispensed from this NEW location?(Required) Yes No Do the owners of this NEW location own the frame inventory from which frames are dispensed?(Required) Yes No Does the frame inventory at this NEW location include a minimum of 250 frames of varying styles, colors, and gender?(Required) Yes No Is the ownership for this NEW location a sole proprietorship, Professional Corporation, Corporation, LLC or partnership? (Ownership must be by one or more physicians who also belong to NVA and work full or part-time at the office.)(Required) Yes No Is the NEW location inside an optical store that you do not own?(Required) Yes No Is there 24/7 access to the NEW location and patient records for emergency or urgent care situations for this location?. (A voice mail message on the office number telling patients to call 911 DOES NOT meet this requirement. A voice mail message must name an optometrist or ophthalmologist and their after hours number, or direct the patient to a “call panel” of doctors who provide emergency coverage.)(Required) Yes No Describe your call coverage for this NEW location (Tell us specifically what your arrangements are and list the doctors who provide coverage when you are not available):(Required)Check the description that best describes the setting of this NEW location:(Required) Free-standing, professional office Office in a medical office complex Office inside a retail store or optical store Other Other:(Required)List all optometrists and ophthalmologists who provide services at this new location. For each doctor, attach a copy of their Professional License showing them at this practice location. How many optometrists and ophthalmologists provide services at this new location?(Required)OneTwoThreeFourFivePhysician’s Name:(Required)Hours worked per week at this location:(Required)National Provider Identification number (NPI):(Required)Physician’s Name:(Required)Hours worked per week at this location:(Required)National Provider Identification number (NPI):(Required)Physician’s Name:(Required)Hours worked per week at this location:(Required)National Provider Identification number (NPI):(Required)Physician’s Name:(Required)Hours worked per week at this location:(Required)National Provider Identification number (NPI):(Required)Physician’s Name:(Required)Hours worked per week at this location:(Required)National Provider Identification number (NPI):(Required)Current W-9 (signed and dated in the last 30 days)(Required)Max. file size: 2 MB.If any physicians listed in this application also need to be REMOVED from another office location or another practice, tell us by submitting the NVA “REMOVE or ADD DOCTOR” FORM.