Appendix 9998. FORMS (14VAC5-216)

Latest version.

External Review Request Form, Form 216-A (eff. 7/11)

Appointment of Authorized Representative, Form 216-B (eff. 7/11)

Physician Certification Expedited External Review Request, Form 216-C (eff. 7/11)

Physician Certification Experimental or Investigational Denials, Form 216-D (eff. 7/11)

Independent Review Organization Application for Registration, Form 216-E (rev. 7/14)

Health Carrier External Review Annual Report Form, Form 216-F (eff. 7/11)

Independent Review Organization External Review Annual Report Form, Form 216-G (eff. 7/11)

Self-Insured Plan Opt-In to Virginia External Review Process, Form 216-H (eff. 7/11)

                    
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