Provider Exception Request Form

Thank you for your interest for participation in ValueOptions' provider network. This form is for practitioner use only. If you are a facility, click here to visit our Contact Us page and send an email to your regional Provider Relations office to request information about joining our network.

Should you have any questions regarding the Exception Request Application Form, please contact 1-800-397-1630 for more information.

Exception Request Form

Question 1

What licensure do you currently hold? (Please indicate the highest level of licensure for which you are allowed to practice independently in your state.)

Other Licensure

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Question 2

Since receiving your license have you been in clinical practice for three (3) years or more?

Yes No

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Question 3

Do you carry the minimum amount of liability insurance?

Yes No

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Question 4

Do you hold a license that allows you to practice independently in your state?

Yes No

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Question 5

Is your license unrestricted?
(Answering YES to this question confirms you have no licensure sanctions/ probation and that you are not currently suspended or facing suspension.)

Yes No

Prior to submission, please review ValueOptions Provider Credentialing Criteria to ensure that you meet these minimum standards. Please complete the following form in its entirety. Incomplete forms will not be reviewed.

A. Provider Information

	Gender
	Male			Female

Last Name

First Name

Mailing Address Line 1

Mailing Address Line 2

City

County

State

Zip

Phone in (nnn-nnn-nnnn) format

Professional Designation or Title (e.g.; Mr. Ms, Dr., etc.)

SSN in (nnnnnnnnn) format

DOB in (yyyy-MM-dd) format

Indicate any other name you may have used in the past (e.g., maiden name, etc.)

Internet E-mail address (if applicable)

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B. Do you possess a license that meets VO criteria for your current licensure and/or specialty network?
(verify with VO criteria requirements located at Provider Credentialing Criteria.

Yes No ( must check one)

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C. Do you possess a license that meets VO criteria for your current licensure for a specialty network? (verify with VO criteria requirements located at Provider Credentialing Criteria.

Yes No ( must check one)

Check each specialty network(s) you wish to consider


	EAP (all licensure levels)
	Disability Assessment Specialist (MD/DO and PhD only)
	Disability Treatment Specialist (all licensure levels)
	Fitness for Duty (MD/DO and PhD only)

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D. Evidence of Training and Clinical Specialty, Language or Cultural Competency

1. CLINICAL EXPERTISE (SPECIALTIES): From the list below, rank order a maximum of five (5) specialty areas for which you have training and expertise. For example “1” means primary specialty, “2” means secondary specialty, etc. If you do not rank order or indicate more than five specialties, they will not be taken into consideration for review of the network. Please remember to select applicable specialties when applying for the specialty networks.

Addictions, Non-Chemical (S.ANC)

Adoption (S.ADP)

Affective Disorders (S.AFF)

Alcohol/Chemical Dependency (S.ACD)

Anger Management/Impulse Disorders (S.ANG)

Anxiety Disorders (S.ANX)

Attention Deficit Hyperactivity Disorder (ADHD)/School-related problems (S.ADD)

Autistic Disorder/Aspergers Syndrome (S.ASP)

Childhood Behavioral Disturbances (S.CBD)

Chronic Pain (S.CHP)

Co-Occurring Disorders (S.COD)

Death & Dying/Terminal Illness (S.CHT)

Disability Assessment (M.DSA)

Disability Treatment (S.DST)

Dissociative Identity Disorders (S.MPD)

Domestic Violence (S.VIO)

Eating Disorders (S.EAT)

Fitness for Duty Assessment (M.FDE)

Forensics (S.FOR)

Gangs/Cults (S.GNG)

Gay/Lesbian/Bisexual Issues (S.GLS)

Geropsychiatry/Alzheimers (S.GAL)

Grief/Bereavement (S.GRF)

Head Trauma (S.HTR)

Hearing Impaired (S.HIM)

HIV/AIDS (S.HIV)

Martial/Separation/Divorce (S.MAR)

Men's Issues (120C) (S.MEN)

Mental Retardation/Developmental Disabilities (S.MRI)

Military Lifestyle Issues (S.MIL)

Neuropsychology (S.NEU)

Obsessive Compulsive Disorder (S.OCD)

Panic/Phobia (S.PHO)

Personality Disorders (S.PER)

Physical Abuse Perpetrators (S.PAP)

Physical Abuse Victims (S.PAV)

Post-Traumatic Stress Disorder (S.PSD)

Reactive Attachment Disorder (S.RAP)

Schizophrenia (S.SCH)

Severe & Persistent Mental Illness (S.SPM)

Sex Abuse Perpetrators (S.SAB)

Sex Abuse Victims (S.SAB)

Sexual Dysfunction (S.DYF)

Sleep Disorders (S.SLP)

Trichotillomania (S.TRM)

Women's Issues (S.WMN)

Worker's Comp Evaluations (M.WCE)

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2. Language: Identify any foreign language(s)/sign language that you use fluently in treating patients

	American Sign Language (SG)	Arabic (AR)	Armenian (AN)
	Chinese (CH)	Dutch (DU)	Farsi (FA)
	French (FR)	German (GE)	Greek (GR)
	Hebrew (HE)	Hindi (HI)	Hungarian (HU)
	Italian (IT)	Japanese (JA)	Korean (KO)
	Norwegian (NW)	Polish (PL)	Portuguese (PO)
	Russian (RU)	Spanish (SP)	Swedish (SW)
	Tagalog/Filipino (PH)	Vietnamese (VI)	Yiddish (YI)
	Other (OT)
Other Language

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3. Cultural Competency: Identify any ethnic group with which you have training and clinical expertise.

	African American	Asian	Cuban/Haitian
	Hispanic/Latino	Jewish	Middle Eastern
	Multiracial	Muslim	Native Alaskan
	Native American	Other
Other Culture

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I certify that all information provided to ValueOptions is true and correct to the best of my knowledge and belief. I agree to notify ValueOptions promptly if there are any material changes in the information provided, whether prior to or after my acceptance as a ValueOptions participating provider. I understand and agree that if ValueOptions discovers that my application contains any significant misstatement, misrepresentations, or omissions, ValueOptions may void, in its sole discretion, this application and any related participating provider agreements.

Signature Date