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What is your relation to Vālenz?

Your email address

Subject

What is your issue about?

Policy Holder Name

The name of the policy holder this request is about

Member Phone Number

Member Employer or Insurance Group

Member ID

Member ID found on your insurance card

Policy Holder DOB

The DOB of the policy holder this request is about

Provider Name

Provider Address

Provider Phone Number

Provider Specialty

Requester Name

Requester Phone Number

Precertification disclaimer

You understand precertification does not guarantee payment or coverage

Date of Service

Enter date of service for the procedure

Procedure Code

Enter procedure code (CPT/HCPS code) You may enter multiple codes using a comma to separate.

What procedure are you having done

Diagnosis Code (ICD 10)

Enter the diagnosis code (ICD10 code) You may enter multiple codes using a comma to separate.

Diagnosis Description

Benefit Disclaimer

You understand Precertification only identifies medical necessity and does not identify benefits.

Eligibility Disclaimer

You have/will call the benefits/eligibility number on the ID card to verify coverage.

Relationship to Insured

Patient Name

Patient Date of Birth

Patient Phone Number

Patient Address

Street Address, City, State, Zip

Physician Phone Number

Physician Address

Physician Name

The name of the physician rendering the services

Facility Name

The facility name where these services are being provided

Facility Tax ID

Facility Address

Facility Phone Number

Admission Type

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

Inpatient Setting

Service Type

DME Type

Reason for referral

Enter the reason for the referral.

Zip Code

Attachments

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