Value Options
  
  1. Provider  
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  2. Referral  
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  3. Practice  
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  4. Education  
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  5. License/Certification  
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  6. Insurance  
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  7. Work History  
  8. EAP Counselor  
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  9. Disability Provider  
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  10. FFD Specialist  
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  11. Provider Profile  
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  12. Attestation  
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  13. W-9  

2. REFERRAL INFORMATION
 
A. LICENSED DISCIPLINE: Indicate the discipline under which you are LICENSED and/or CERTIFIED at the highest level to practice independently.
APN w/ Prescriptive Authority (NP or CNS)
APN w/o Prescriptive Authority (NP or CNS)
Doctor of Osteopathy
Licensed /Certified Social Worker (Highest Level)
Licensed Clinical Psychologist (Doctorate Level)
Licensed Clinical Social Worker (Highest Level)
Licensed Marriage and Family Therapist (Highest Level)
Licensed Mental Health Counselor (Highest Level)
Licensed Professional Counselor (Highest Level)
MD - Addictionologist
MD - Child/Adolescent Psychiatrist
MD - Developmental Behavioral Pediatrician
MD - Geriatric Psychiatrist
MD - Psychiatrist
Master's Level Psychologist
Other
Pastoral Counselor
Other (specify):
 
 
B. Population Treated:
Identify the percentage of your practice dedicated to the following patient population categories (must total 100%)
Population % of Practice
Are You Currently
Accepting New Patients?
Yes     No
 Modality % of Practice
Child(0-5)
     
Inpatient
Child(6-12)
     
Day Treatment
Adolescent(13-17)
     
Outpatient
Adult(18-64)
     
Intensive Outpatient Programs
Geriatric(65+)
     
C. Language:
Identify any foreign language(s) or sign language that you use fluently in treating patients (select no more than 5):
AMERICAN SIGN LANGUAGE
ARABIC
ARMENIAN
CHINESE
DUTCH
FARSI (PERSIAN)
FRENCH
GERMAN
GREEK
HEBREW
HINDI
HUNGARIAN
ITALIAN
JAPANESE
KOREAN
NORWEGIAN
POLISH
PORTUGESE
RUSSIAN
SPANISH
SWEDISH
VIETNAMESE
YIDDISH
Other (specify):
 
D. ANSWERING SERVICE: Indicate how you can be reached after hours:
Answering Service Name
Phone # Pager or Beeper #
Voice Mail #
 
E. CLINICAL EXPERTISE (SPECIALTIES): From the list below, rank order a maximum of six (6) specialty areas for which you have training and expertise. For example "1" means primary specialty, "2" means secondary specialty, etc. If you indicate more than six specialties, they will not be documented. These specialties will be used to assist ValueOptions, Inc. in making clinically appropriate referrals. Please remember to select applicable specialties when applying for the specialty networks.
  1. 
  2. 
  3. 
  4. 
  5. 
  6. 
 
F. THERAPEUTIC MODALITIES: From the list below, rank order a maximum of six (6) modality areas that you use when treating patients. For example "1" means primary modality, "2" means secondary, etc. These modalities will be used to assist ValueOptions, Inc. in making clinically appropriate referrals. Please remember to select applicable modalities when applying for the specialty networks.
  1. 
  2. 
  3. 
  4. 
  5. 
  6. 
 
G. VOLUNTARY INFORMATION: To meet the needs of ValueOptions Inc. clients and members, voluntary information is maintained about providers for referral and statistical purposes only. This information is released to members only upon specific request. If you wish to provide this information, select from the following categories:
African-American / Black
American Indian
Asian
Biracial
Caucasian
Christian
Hispanic
Jewish
Muslim
West Indian
 
H. HOSPITAL PRIVILEGES: List below, if applicable, your current hospital privileges and the type of hospital privilege granted to you by your admitting facility. The Primary Admitting Facility should be the facility at which you admit/treat most of your patients.
Do you currently hold hospital privileges? Yes No
Edit Name Address City/ST/Zip Delete
No Records Found
If you do not have admitting privileges, list the name(s) of an in-network physician or facility below to whom you would refer.
 
First Name Last Name Facility Name
 
* You may call the National Network Services Line at (800) 397-1630 to verify network participation.
 
  
 
 

© 2012 ValueOptions® ProviderConnect v3.27.00