Get Authorization Request Form - Valley Health Plan

Filling out the Authorization Request Form for Valley Health Plan is an essential step to ensure that users receive the necessary services and support. This guide provides clear, step-by-step instructions on how to accurately complete the form online.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In Section 1, provide the patient's information. Enter the first and last name, date of birth, and check the appropriate box for their gender. Additionally, input the patient's current address, phone number, Social Security number, Health Plan ID, and diagnosis or ICD9 code.
3. Move to Section 2, where you will check the type of service needed (emergency, urgent, routine, or retrospective) and the appropriate program or line of business the patient is enrolled in. You will also need to enter the requested provider's name, location, and contact details.
4. In Section 3, detail the specific services requested. Enter the CPT4 or HCPC code relevant to the procedure, quantity of procedures needed, and the length of time for which the services will be required. Also, provide a medical justification for the request.
5. Section 4 is to be completed by Valley Health Plan and includes approval information. Leave this section blank when filling out the form.
6. Section 5 requires the requesting provider's information. Print your name, sign the form, and include the date.
7. For the final step, review all sections for accuracy. Once completed, you can save the changes, download, print, and share the form as needed.

Ensure timely processing of your request by completing the Authorization Request Form online now.