ValueOptions Provider Data Sheet

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9. DISABILITY PROVIDER NETWORK ONLY

Are you interested in participating in the Disability Provider Network specialty network?	Yes	No
If yes, go on.
Do you meet the minimum VO criteria for your licensure level AND the criteria for the Disability Provider Network specialty network?	Yes	No
If yes, complete the following for the Disability Provider Network specialty network in its entirety.


A. Disability Assessment Specialists - Psychiatrists and Psychologists Only
1.	Indicate how many years of experience you have assessing patients with psychiatric disabilities
	2-4 5-7 8-10 11-13 more than 13
2.	Indicate how many patients you have evaluated in which psychiatric disability was an issue
	0-10 11-20 21-35 36-50 more than 50
3.	Indicate in the table below by checking the appropriate box the number of each type of disability related evaluations you have done in the past 2 years
		<=10	11-30	31-50	51-70	>71
	Primary Psychiatric
	Secondary psychiatric where medical disability was primary
	Forensic
	Worker's Compensation
4.	Will you routinely be able to accept referrals from ValueOptions Disability Care Managers within 24 hours?				Yes	No
5.	Will you routinely be able to conduct face-to-face disability evaluations of ValueOptions referred patients within 72 hours of referral?				Yes	No
6.	If you are a psychologist, do your administer, score and interpret psychological tests as part of you assessment process?				Yes	No
7.	Certification
	a. Is QME (Qualified Medical Examiner) certification available in the state where you practice?			Yes	No	N/A
	b. Do you have QME certification?			Yes	No	N/A
	c. Are you certified by the American Board of Independent Medical Examiners?			Yes	No	N/A
	d. Are you eligible for certification by the American Board of Independent Medical Examiners?			Yes	No	N/A
	e. Are you a member of the American Academy of Psychiatry and the Law?			Yes	No	N/A
	f. Are you a member of the American Board of Forensic Psychology?			Yes	No	N/A

B. Disability Treatment Specialists - All Disciplines
1.	Indicate how many years of experience you have treating patients with disabilities
	2-4 5-7 8-10 11-13 more than 13
2.	In the past 2 years, indicate how many patients you have treated in which disability was an issue
	0-10 11-20 21-35 36-50 more than 50


C. All Disability Network Applicants (continued) - Assessment and/or Treatment Specialists
1.	What is your primary focus when developing a treatment plan for disability cases? (Check all that apply)
	Impact of impairment on job functions		Type of treatment
	Workplace issues		Psychosocial/medical issues
2.	Are you willing to make collateral contacts with employers, family members, other providers, etc.?			Yes No
3.	Indicate the settings where you have experience with disability cases and the number of cases you served in that setting in the past two (2) years.
	Inpatient hospital	Number of cases:	Rehabilitation center	Number of cases:
	Intensive outpatient program	Number of cases:	Workplace	Number of cases:
	Outpatient	Number of cases:
4.	Are you willing and able to communicate with a ValueOptions Disability Care Manager on an ongoing and consistent basis?			Yes No

� 2011 ValueOptions^® ProviderConnect v3.22.00