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

Filling out the Out Of Network Request Form is an essential step for members seeking to receive services from out-of-network providers. This guide aims to provide clear and instructive steps to help you complete the form accurately, ensuring that all necessary information is included.

Follow the steps to complete the Out Of Network Request Form efficiently.

1. Press the ‘Get Form’ button to access the Out Of Network Request Form. Open it in your preferred editor to begin.
2. Complete the member information section by filling in your name, member number (19 digits), date of birth, and primary care provider (PCP) information. Ensure that all asterisked fields are accurately filled out to identify the member and the requested service.
3. In the provider/practitioner information section, fill in the name of the referring physician, office contact details, phone number, and fax number. Specify the requested Out Of Network practitioner/provider, including their specialty type and contact information.
4. If applicable, provide information about the facility where the requested procedure will take place. Fill in the facility's name, address, contact number, and contact person.
5. Indicate if a network specialist evaluated the member by selecting yes or no. Fill in the requested service (5-digit CPT code), the requested date of service, and the service location (office or home).
6. Select whether the request is for an initial request, extension request, non-urgent service, or clinically urgent service. Specify if the date of service (DOS) is scheduled, not scheduled, or retrospective.
7. If applicable, specify the number of visits needed, and indicate whether the service will be outpatient or inpatient.
8. Ensure to include all required documentation with your request. This includes clinical documentation supporting the need for services and any other pertinent information that may help in reviewing your request.
9. Once all information is filled out, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Out Of Network Request Form online today to ensure your request is processed without delay.