Get Vbh Continuation Rights Form

This guide provides a comprehensive walkthrough for completing the Vbh Continuation Rights Form online. By following these instructions, you will ensure that you fill out the form accurately and submit it timely.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's name and MAID number. Ensure this information matches the records for accuracy.
3. Next, fill in the provider's name, the current Plan of Care (POC) dates, and the previous POC dates.
4. Select between Option A and Option B regarding the services the family chooses. Ensure to indicate the authorized services for the chosen option.
5. Indicate the level of appeal that has been requested by checking the corresponding box.
6. Confirm whether the grievance or fair hearing was filed by the effective date on the denial letter by selecting 'Yes' or 'No.'
7. Certify that the member/family is aware of the options for continuation rights and provide the provider signature along with the date.
8. On page 2, check either Option A or Option B again, then fill in the member's name, date of birth, MAID number, provider name, phone number, provider address, and details regarding previous and current POC dates.
9. Provide the hours to be authorized for each service listed, ensuring accuracy for proper service continuation.
10. Finally, sign and date the form as the provider and ensure both pages of the form are completed before submission.

Complete and submit the Vbh Continuation Rights Form online today for timely processing.