Get Physician's Notification Form

The Physician's Notification Form is essential for documenting situations where a provider deems that a screening or requirement should be exempted. This guide will assist you in completing the form accurately and efficiently.

Follow the steps to complete the form properly.

1. To obtain the form, click the ‘Get Form’ button and open it in your preferred online tool.
2. Begin by entering your personal information in the Member Information section. Ensure that all details match what is displayed on your Medical/Dental Plan ID card, including your Member Identification Number, Last Name, First Name, and Date of Birth.
3. Complete the remaining sections of the Member Information by filling in your Group Number, Employee ID, Middle Initial, Department ID, Home Address, City, State, Zip Code, Telephone, and Email Address.
4. In the Provider Information section, provide the name of your healthcare provider or clinic, their Provider ID (if applicable), office address, and contact details, including telephone and fax numbers.
5. Indicate the relevant screenings and services your provider is reporting by checking the appropriate boxes. Ensure that you have included the dates for any completed screenings or noted exemption reasons as necessary.
6. If any screenings are marked as exempt, please provide a brief explanation from the provider regarding the reason for each exemption in the designated area.
7. Both the member (or parent/guardian) and provider must sign and date the form at the bottom to validate the information before submission.
8. After completing the form, save any changes made. You may wish to download, print, or share the completed form as required.

Take the next step and complete your documents online today.