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Get Mvp Claim Adjustment Form

DEPT OF VERMONT HEALTH ACCESS 312 Hurricane Lane Suite 201 Williston VT 05495 Telephone 802 879-5903 Fax 802 879-5963 DVHA CLINICAL UNIT VERMONT MEDICAID PRE-PROCEDURE REQUEST FORM Date of Request Date if Procedure has been scheduled Procedure is Elective Urgent Setting where procedure will be performed N/A Procedure has not been scheduled Emergent Does not require prior authorization.

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