Remove or Add a Doctor Form

WAIT! DO NOT USE THIS FORM to add a doctor to a practice location that is new to NVA* or to add a doctor who is not yet an NVA Member. If you are opening a new practice or buying an existing practice, use the NVA “Add a New Location” form. If a doctor is not yet an NVA Member, list the practices where they will be providing services in their NVA application. All NVA forms are available online at: www.nwvisionassociates.com.

DO use this form to: 1) REMOVE an NVA Member entirely from a practice; 2) REMOVE an NVA Member from one or more practice locations; or 3) ADD an NVA Member to a practice location listed with NVA*.

STEP 1: TELL US THE NAME OF THE DOCTOR AND NPI:

Name of Doctor:(Required)

Doctor NPI(Required)

STEP 2: TELL US WHAT TO DO

You would like us to:(Required)

REMOVE the doctor from ALL office location(s) associated with TIN shown below.

REMOVE the doctor ONLY from the office location(s) shown below.

ADD this doctor only to the office location(s) shown below.

REMOVE the doctor from practice locations for the TIN below because:(Required)

Retired

Resigned

Moved

Went to a non-NVA practice

Maternity Leave

Other (explain below)

Other:(Required)

FORWARDING ADDRESS of doctor being removed (if left blank we will send all notices c/o the practice to forward):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Practice:(Required)

Tax ID Number:(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Practice?

Yes

Name of Practice:

Tax ID Number:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Practice?

Yes

Name of Practice:

Tax ID Number:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Practice?

Yes

W-9

Max. file size: 2 MB.

When adding a new provider please attach a current W9 that has been signed and dated in the last 30 days.

Professional Liability Certificate

Max. file size: 2 MB.

When adding a new provider please attach a current copy of the professional liability insurance certificate. Certificate can either be solely in the provider’s name or in the practice name but provider’s name must also be included.

Today’s date:(Required)

Date change(s) effective:(Required)

Person completing this form:(Required)

First Last

Telephone Number:(Required)

Fax Number:

Email Address:(Required)

STEP 1: TELL US THE NAME OF THE DOCTOR AND NPI:

STEP 2: TELL US WHAT TO DO

***IF SUBMITTING AN ADD FORM YOU WILL ALSO NEED TO SUBMIT A PAYER PARTICIPATION FORM AND CURRENT W9 SIGNED IN THE LAST 30 DAYS***

IF SUBMITTING AN ADD FORM YOU WILL ALSO NEED TO SUBMIT A PAYER PARTICIPATION FORM AND CURRENT W9 SIGNED IN THE LAST 30 DAYS