Get Member Advance Notice Form For The Involvement Of A Nonparticipating Provider

Filling out the Member Advance Notice Form is essential for individuals engaging with nonparticipating providers. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring you understand your rights and options regarding your healthcare decisions.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by filling in the physician or health care professional's name in the designated field.
3. Enter the Tax ID number of the physician or health care professional in the specified section.
4. Provide your name as the member in the appropriate field.
5. Input your Member ID number as it appears on your health plan ID card.
6. Fill in the name of the nonparticipating physician, facility, or healthcare provider you are using.
7. Specify the type of service the nonparticipating provider will render, such as lab or dialysis.
8. Indicate the date of service for which you are requesting nonparticipating provider involvement.
9. Provide the reason for involving a nonparticipating provider in your care in the designated field.
10. Read the acknowledgment statement about your choice to use a nonparticipating provider, and then sign the form at the bottom.
11. Print your name and enter the date in the specified fields.
12. Include a telephone number where you can be reached.
13. Once all fields are completed, review the form for accuracy, then save changes, download, print, or share the form as needed.

Complete your documents online today and ensure your healthcare choices are well-informed.