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  • Empire Open Network Physician Written Mri Order Form 2007

Get Empire Open Network Physician Written Mri Order Form 2007-2025

Hone *Date of Birth *Work Phone: *SSN Cell Phone: *Physician s Name (Please Print) Billing Information: Health MVA/NF Physician s Phone: PreCert/Authorization: Physician s Fax: Insurance Company: W/Comp Other Policy#: Requested MRI/MRA Procedure Brain Knee Cerviceal Ankle Thoracic Foot Lumbal Wrist Prostate Elbow Abdomen Shoulder Pelvis Thigh Orbits Lt. Rt. Other Scan Type: Diagnosis: ICD-9 Dx Codes , Requesting Appointme nt Date: Lt. Lt. Lt. Lt. Lt. Lt. Lt. Rt. Rt. Rt. Rt.

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Single $35 copayment for all covered services provided during the visit by a participating laboratory. $80 copayment for MRI, MRA, CT Scan, PET Scan and Nuclear Medicine test.

About the Program The Empire Plan is the primary health insurance plan for NYSHIP, covering 1.1 million members. Civil Service contracts with UnitedHealthcare Insurance Company of New York (United) to administer the Empire Plan's medical/surgical benefits.

What is The Empire Plan? A. The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. The Empire Plan pays for covered hospital services, physicians' bills, prescription drugs and other covered medical expenses.

Your SEHP medical coverage will be through insurance carriers under contract with NYSHIP: Empire Blue Cross Blue Shield (for hospital benefits), UnitedHealthcare Insurance Company of New York (medical/surgical), GHI/ValueOptions (mental health and substance abuse) and CIGNA/Express Scripts (prescription drugs).

They have not agreed to a contract with your insurance company and may charge higher rates for the same services. However, this doesn't mean your insurance company will pay these higher rates. If your insurance company provides out-of-network coverage, it may only pay the amount it would for an in-network service.

When a doctor, hospital or other provider accepts your health insurance plan we say they're in network. We also call them participating providers. When you go to a doctor or provider who doesn't take your plan, we say they're out of network.

UnitedHealthcare administers The Empire Plan's medical portion, and its Empire Plan Network was specifically developed to serve the needs of The Empire Plan.

Medical/Surgical Program The Empire Plan is designed to provide enrollees with comprehensive medical care coverage. Using participating providers helps keep the cost to you and The Empire Plan at a reasonable level. UnitedHealthcare is the program administrator for this coverage.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232