Out-of-Network Coverage Exception Request
Request an exception for health insurance coverage of out-of-network services.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Email Address
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Member ID
*
Insurance Plan Name
*
Requesting Provider Name and Specialty
*
Out-of-Network Provider Name and Facility (if different)
Requested Service or Procedure (please specify CPT/HCPCS code if known)
*
Diagnosis or Medical Reason for Request
*
Clinical Justification for Out-of-Network Exception (explain why in-network options are not appropriate)
*
Upload Supporting Documentation (e.g., referral letter, medical records, clinical notes)
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