Clinical Forms

Outpatient Treatment Report Forms

For most efficient and timely service – use of authorization request flow on ProviderConnect® is the preferred method of submitting requests. Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

Inpatient and Higher Levels of Care Authorization Requests

For most efficient and timely service — use of authorization request flow on ProviderConnect® is the preferred method of submitting requests. ValueOptions is no longer accepting faxed Inpatient Treatment Review (ITR) requests for Acute Mental Health or Acute Detox Services for its commercial contracts.

Please submit requests via ProviderConnect, our secure HIPAA-compliant provider application. Alternatively, you may contact us by dialing the toll-free number on the member’s insurance card to complete a telephonic review during normal business hours Monday through Friday. After hour requests, occurring past normal business hours on Friday or Saturday, may be called in as well.

Continue to submit Residential, Partial and Intensive Outpatient service requests on-line. If you are unable to complete the request on-line, please contact customer service by dialing the toll-free number on the member’s insurance card to obtain information on the correct procedure to utilize.

Faxed or mailed forms should only be submitted to the specific fax or address. Please confirm for a specific contract that forms are allowed. Some contracts allow only telephonic review if web service is not utilized. Some contracts require that requests only be submitted via the web.

Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS) Forms

Psychological Evaluation Forms

Treatment Coordination Forms

Treatment Record Review Forms

Guides and Resource Documents

Applied Behavioral Analysis (ABA) Treatment Forms