Get Nonparticipating Provider Request Form - Hr Virginia

This guide provides step-by-step instructions for completing the Nonparticipating Provider Request Form - Hr Virginia online. It is designed to assist users in filling out the form accurately and efficiently while ensuring all required information is submitted.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the Requesting Provider Information section. This includes entering the provider's name (first, middle initial, last), provider ID number, contact name, telephone number, signature, and the request date.
3. Next, complete the Patient Information section. Enter the patient's name (first, middle initial, last), date of birth, ID number, address, and telephone number.
4. In the Nonparticipating Provider Information section, provide details for the nonparticipating provider, including their name (first, middle initial, last), telephone number, address, fax number, specialty or provider ID number. Indicate whether there has been an attempt to find an Aetna network provider and whether the patient has seen this provider previously, including the date of the last visit if applicable.
5. Move on to the Reason for Nonparticipating Provider Request section. List the services needed, diagnosis codes, and procedure/CPT codes. Provide a brief explanation for why the services must be rendered by this particular specialist. Additionally, indicate whether the member has out-of-network benefits they intend to use.
6. Review the completed form for accuracy and ensure all required fields are filled out correctly.
7. Once all information is inputted and verified, you can save your changes, download the completed form, print it, or share it as required for submission.

Complete your documents online and ensure your requests are processed promptly.