Managed Long-Term Services and Supports Provider Area Service Form
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1 Managed Long-Term Services and Supports Provider Area Service Form This form is for Anthem HealthKeepers Plus members on behalf of HealthKeepers, Inc. Provider name and doing business as per W-9: TIN: NPI: Please indicate below the type of services your agency provides. Home health Private duty nursing Personal care (skilled nursing visits) (hourly skilled nursing) Physical therapy Pediatric care Respite Speech therapy Ventilator care needs Service facilitator Occupational therapy Complex tracheostomy care Assistive technology Additional service(s): Attestation: I hereby affirm that our agency is in compliance with the provider waiver requirements as established in the Department of Medical Assistance Services provider manuals available at and the following regulations: 12VAC through 12VAC I also affirm that the service area information is reflective of our current service area capabilities and will need to be updated as modified by our organization s capabilities. Signature: Printed name/title: Date: Telephone: Check here if you service Virginia statewide. If so, there is no need to proceed. If you do not service Virginia statewide, review the remainder of the document and check the applicable service areas by region. Central region If you service all cities in the Central region, please check this box. Amelia (007) Amelia Lancaster (103) Lancaster Brunswick (025) Lawrenceville Lunenburg (111) Lunenburg Caroline (033) Bowling Green Mathews (115) Mathews Charles (036) Chesterfield (041) Charles Mecklenburg (117) Boydton Chesterfield Middlesex (119) Saluda HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC July 2017
2 Page 2 of 5 Colonial Heights (570) Cumberland (049) Colonial Heights Cumberland Northumberland (133) New Kent (127) New Kent Heathsville Dinwiddie (053) Dinwiddie Nottoway (135) Nottoway Emporia (595) Emporia Petersburg (730) Petersburg Essex (057) Tappahannock Powhatan (145) Powhatan Franklin (620) Fredericksburg (630) Franklin Prince Edward (147) Fredericksburg Prince George (149) Goochland (075) Goochland Richmond (760) Farmville Prince George Richmond Greensville (081) Jarrett Richmond (159) Warsaw Hanover (085) Hanover Southampton (175) Courtland Henrico (087) Henrico Spotsylvania (177) Spotsylvania Hopewell (670) Hopewell Stafford (179) Stafford King and Queen (097) King and Queen Surry (181) Surry King George (099) King William (101) King George Sussex (183) Sussex King William Westmoreland (193) Montross Tidewater region If you service all cities in the Tidewater region, please check this box. Accomack (001) Accomack Northampton (131) Chesapeake (550) Eastville Chesapeake Poquoson (650) Poquoson Gloucester (073) Gloucester Portsmouth (740) Portsmouth Hampton (650) Hampton Suffolk (800) Suffolk Isle of Wight (093) Isle of Wight Virginia Beach (810) James (095) Williamsburg Williamsburg (830) Virginia Beach Williamsburg
3 Page 3 of 5 Newport News (700) Norfolk (710) Norfolk Newport News York (199) Yorktown Northern/Winchester region If you service all cities in the Northern and Winchester regions, please check this box. Alexandria (510) Alexandria Loudoun (107) Leesburg Arlington (013) Arlington Manassas Clarke (043) Berryville Manassas Park Manassas Prince William Culpeper (047) Culpeper Page (139) Luray Fairfax (600) Fairfax Prince William Fairfax County (059) Falls Church (610) Annandale Rappahannock (157) Falls Church Shenandoah (171) Manassas Washington Woodstock Fauquier (061) Warrenton Warren (187) Front Royal Frederick (069) Winchester Winchester (840) Winchester Western/Charlottesville region If you service all cities in the Western and Charlottesville regions, please check this box. Albemarle (003) Charlottesville Halifax (083) Nathalie Amherst (009) Amherst Harrisonburg (660) Appomattox (011) Harrisonburg Appomattox Louisa (109) Louisa Augusta (015) Staunton Lynchburg (680) Lynchburg Buckingham (029) Buckingham Madison (113) Madison Campbell (031) Rustburg Nelson (125) Lovingston Charlotte (037) Charlotte Ct. House Charlottesville (540) Orange ( 137) Orange Charlottesville Pittsylvania (143) Chatham
4 Page 4 of 5 Danville (590) Danville Rockingham (165) Harrisonburg Fluvanna (065) Palmyra Staunton (790) Staunton Greene (079) Stanardsville Waynesboro (820) Waynesboro Roanoke/Alleghany region If you service all cities in the Roanoke and Alleghany regions, please check this box. Alleghany (005) Clifton Forge Lexington (678) Lexington Bath (017) Hot Springs Martinsville (690) Martinsville Bedford (019) Bedford Montgomery (121) Christiansburg Botetourt (023) Hollins Patrick (141) Stuart Buena Vista (530) Buena Vista Pulaski (155) Pulaski Covington (580) Covington Radford (750) Radford Craig (045) New Castle Roanoke (770) Roanoke Floyd (063) Floyd Roanoke (161) Roanoke Franklin (067) Rocky Mount Rockbridge (163) Vinton Giles (071) Pearisburg Salem (775) Salem Henry (089) Bassett Wythe (197) Wytheville Highland (091) Monterey Southwest region If you service all cities in the Southwest region, please check this box. Bland (021) Bland Norton (720) Norton Bristol (520) Bristol Russell (167) Lebanon Buchanan (027) Grundy Scott (169) Gate Carroll (035) Hillsville Smyth (173) Marion Dickenson (051) Clintwood Tazewell (185) North Tazewell Galax (640) Galax Washington (191) Abingdon Grayson (077) Independence Wise (195) Wise
5 Page 5 of 5 Lee (105) Jonesville
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55100 Accomack County (275,883) 3,037,806-2,278,355-41,204 942,874 79,602 918,486 628,762 628,762-55101 Albemarle County 28,184,164 7,590,704-5,693,028-73,801 2,422,775 3,201,583 5,007,572 30,772,427 30,772,427-55102
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