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Get Out Of Network Request Form (Forms) - Physicians Health Plan

P.O. Box 30377 Lansing, MI 48909-7877 Phone: 517-364-8560 Fax: 517-364-8409 OUT OF NETWORK (OON) REQUEST FORM The bolded items with an asterisk are needed to identify the member and the requested.

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  • OUTPATIENT
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