Follow the steps to complete your GAP exception request form.

1. To begin, press the ‘Get Form’ button to access the GAP Exception Request Form in your preferred editor.
2. In the 'Member Information' section, fill in your full name, DMC Care ID number, address, phone number, and date of birth. Ensuring accuracy is essential for proper identification.
3. Next, move to the 'Provider/Facility Information' section. Here, enter the name of your provider or physician, their contact number, and the facility's address. Additionally, specify the provider's specialty and tax ID, as well as the NPI number.
4. In the 'Procedure/Service Information' section, provide details about your diagnosis and describe the procedure you will undergo. Include the relevant procedure and diagnosis codes (CPT & ICD-9) as well as the expected date of service.
5. Indicate the reason for your gap exception request by checking the appropriate box. Options include services not being available within 45 miles, emergency admissions, or specific medical needs that cannot be met at a Tenet facility. If applicable, explain your situation in the comments section provided.
6. After completing all sections, review your form for any errors. Once confirmed, proceed to save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your GAP Exception Request Form online today to ensure timely approval for your necessary services.