Get Online Provider Services Account Request Form ... - Value Options

This guide aims to assist users in completing the Online Provider Services Account Request Form for Value Options accurately and efficiently. By following these steps, users can ensure that all necessary information is provided for smooth processing.

Follow the steps to complete your form successfully.

1. Press the ‘Get Form’ button to retrieve the form and open it in your document viewer.
2. Begin by filling in the Provider, Practice, or Facility Name in the designated field at the top of the form.
3. Enter your ValueOptions assigned Provider ID. If you are unsure of this number, you may need to reach out to the relevant provider contacts listed on page 3 of the form.
4. Input your Practice or Facility Tax ID without including any dashes.
5. List your ValueOptions assigned Vendor Number(s). If you are uncertain about these numbers, please consult the provider contacts on page 3.
6. Complete the Address Line 1 and Address Line 2 fields with your physical address.
7. Fill in your City, State, and Zip Code accurately to ensure proper routing of correspondence.
8. Provide your telephone and fax numbers as requested, ensuring accuracy for communication purposes.
9. Select the Online Provider Services options you wish to access by checking the appropriate boxes.
10. Indicate whether the provider will be submitting claims or if a Billing Agent or Clearinghouse is being used by answering the respective questions.
11. For specific states, confirm whether you will be submitting Medicaid claims by providing the corresponding answers.
12. In the Contact e-mail address field, enter the email address at which you would like to receive communications and feedback.
13. Complete the signature section at the bottom of page 2, including your legal name of the organization and title.
14. Once all information is accurately filled out, review the form for any errors before submitting.
15. Finally, fax pages 1 and 2 of the completed form to the designated number: 866-698-6032.

Start filling out your Online Provider Services Account Request Form today for efficient processing.