Va. Admin. Code tit. 14, agency 5, ch. 216, pt. III, form FORMS (14VAC5-216) - FORMS (14VAC5-216)
External Review Request Form, Form 216-A (7/11).
Appointment of Authorized Representative, Form 216-B (7/11).
Physician Certification Expedited External Review Request, Form 216-C (7/11).
Physician Certification Experimental or Investigational Denials, Form 216-D (7/11).
Independent Review Organization Application for Registration, Form 216-E (7/11).
Health Carrier External Review Annual Report Form, Form 216-F (7/11).
Independent Review Organization External Review Annual Report Form, Form 216-G (7/11).
Self-Insured Plan Opt-In to Virginia External Review Process, Form 216-H (7/11).
Notes
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