- W-9 (Editable Version)
- CMS-1500 Claim (PDF)
- Link to Tips for Completing the CMS-1500 (PDF)
- UB04 Claim (PDF)
- Link to Tips for Completing the UB04 (PDF)
- Medicare Waiver of Liability (out of network providers ONLY)
- Out-of-Network Emergency Services and Surprise Bills (NY only)
Billing and Claims Forms
Provider Demographic Updates/Change of Address Forms
- Are you receiving important communications from ValueOptions?
- Are members able to reach you for referral purposes?
- Are manual processes like faxing paperwork and filling out forms by hand taking hours out of your day?
In just a few steps, network providers can submit real time demographic updates electronically via ProviderConnect. Electronically submit demographic updates today or you may fail to receive an important communication or referral opportunity.
ValueOptions recommends providers update their demographic information using ProviderConnect. To update active service locations, addresses, phone numbers, billing locations and other contact information, log into ProviderConnect and click on the “Update Demographic Information” link. Learn more by viewing Section 18 of the ProviderConnect User Guide.
For those providers who prefer to submit demographic updates via mail or fax, the following forms are available:
Provider Notification Forms
- Provider Credentialing Criteria Checklist (PDF)
- Exception Request for Application
- Credentialing Supporting Documentation Forms (for submission with your online recredentialing application when necessary)
- ValueOptions® of California, Inc. Language Capability Attestation
- Roster for ABA Paraprofessional Providers
- Facility Roster
- Group Practice Roster
- Group Practice Tip Sheet
- Online Services Account Request (Editable Version)
- ProviderConnect Account Request Form for Access to Multiple Providers (PDF)
- Online Services Intermediary Authorization (PDF)
- Account Deactivation Form
- Member Release of Information Form (PDF)
- Coordination of Care Authorization Form (PDF)
- Member tip sheet: What your doctor needs to know
- Member release info sheet: PHI